Job Title: Care Review Clinician
Location: Remote (USA)
Schedule: Monday - Friday, 8 AM to 5 PM EST
Experience Required: 3+ years of hospital acute care/medical experience, UM experience
As a Care Review Clinician, you will be an integral part of the Utilization Management team, focusing primarily on inpatient medical necessity/utilization review and various utilization management activities. Your role is crucial in ensuring that MCO (Managed Care Organization) members receive timely, appropriate, and cost-effective care while adhering to state and federal regulations and guidelines.
- Conduct concurrent review and prior authorizations (as needed) according to MCO policy for MCO members as part of the Utilization Management team.
- Identify appropriate benefits, eligibility, and expected length of stay for members seeking treatments and procedures.
- Collaborate with other departments to enhance the continuity of care for MCO members, including Behavioral Health and Long-Term Care.
- Maintain department productivity and quality measures.
- Attend regular staff meetings.
- Assist in mentoring new team members.
- Complete assigned work plan objectives and projects in a timely manner.
- Foster professional relationships with the provider community and internal/external customers.
- Consult regularly with MCO medical directors and refer cases as necessary.
- Comply with required workplace safety standards.
- Strong communication skills, problem-solving abilities, and effective interpersonal interactions.
- Exceptional organizational skills, with the capacity to manage multiple priorities.
- Ability to work independently and handle multiple projects simultaneously.
- Knowledge of applicable state and federal regulations.
- Proficiency in Interqual and other references for length of stay and medical necessity determinations.
- Experience with NCQA.
- Initiative and commitment to task completion.
- Computer literacy, particularly with Microsoft Office products.
- Excellent verbal and written communication skills.
- Adherence to MCO's policies.
- Punctuality and attendance to support required work quality and quantity.
- Maintenance of confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA).
- Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers, and customers.
Required Education: Completion of an accredited Registered Nursing program (a combination of experience and education will be considered in lieu of a Registered Nursing degree).
Required Experience: Minimum 2-4 years of clinical practice, preferably in hospital nursing, utilization management, and/or case management.
Required Licensure/Certification: Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.