Clinical Care Reviewer II - RN - IN MCD - IN or MSL Licensed

Job Summary

Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members, as well as monitoring the delivery of healthcare services.

Essential Functions

• Complete prospective, concurrent and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment
• Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care
• Engage with medical director when additional clinical expertise is needed
• Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards
• Identify and refer quality issues to Quality Improvement
• Identify and refer appropriate members for Care Management
• Provide guidance to non-clinical staff
• Provide guidance and support to LPN clinical staff as appropriate
• Attend medical advisement and State Hearing meetings, as requested
• Absorb special projects or research, as requested
• Perform any other job related duties as requested

Education And Experience

• Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program required
• Three (3) years clinical experience required
• Med/surgical, emergency acute clinical care or home health experience preferred
• Utilization Management/Utilization Review experience preferred
• Medicaid/Medicare/Commercial experience preferred

Competencies, Knowledge and Skills

• Proficient data entry skills and ability to navigate clinical platforms successfully
• Working knowledge of Microsoft Outlook, Word, and Excel
• Effective oral and written communication skills
• Ability to work independently and within a team environment
• Attention to detail
• Proper grammar usage and phone etiquette
• Time management and prioritization skills
• Customer service oriented
• Decision making/problem solving skills
• Strong organizational skills
• Change resiliency

Pay

$62,700.00 - $100,400.00

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance.

Total Rewards

We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Organization Level Competencies

• Fostering a Collaborative Workplace Culture
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business