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Care Review Clinician (Remote) - LPN / RN

Long Beach, CA

Job Title: Care Review Clinician

Location: Remote (USA)

Schedule: Monday - Friday, 8 AM to 5 PM PST

Experience Required: 3+ years of hospital acute care/medical experience and 3 Years of dedicated UM experience

Summary:

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.

Essential Functions:

  • 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.

Knowledge/Skills/Abilities:

  • 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.

Duration: Temp-to-Permanent

Required Licensure/Certification: Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.

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