Care Review Clinician I

 In
  • CONTRACTOR
  • Irving, TX

Website Administrative

Reference Code: 4344

Position Ti?
tle: Care Review Clinician I, 12918-1
Locatio?
n: REMOTE, Irving, TX 75038
Duration: 3 m?
onths 

Notes: %?3C/b>

  • Must have requiremen?
    ts: UM experience, detail oriented, motivated, self-starte?
    r, comfortable with virtual communication
  • D?
    ay to day responsibilities: Review prior authorization requests%?20for medical necessity determination
  • Required%?20Licensure: LVN or RN
  • M-F 8-5 to s?
    tart – would ultimately shift to cover at least a ?
    Sat or Sun each week once trained and independent
  • %?0A

 

Su?
mmary:

  • Works with ?
    the Utilization Management team primarily responsible for inpatien?
    t medical necessity/utilization review and other utilization man?
    agement activities aimed at providing Healthcare members with th?
    e right care at the right place at the right time. Provi?
    des daily review and evaluation of members that require hospit?
    alization and/or procedures providing prior authorizations and/o?
    r concurrent review.
  • Assesses services for%?20Members to ensure optimum outcomes, cost effectiveness and c?
    ompliance with all state and federal regulations and guidelines%?2E

 

%0?
A

Essential Functions:

    %?0D

  • Provides concurrent review and prior authorizations ?
    (as needed) according to  policy for  members%?20as part of the Utilization Management team.
  • %?3Cli>Identifies appropriate benefits, eligibility, and expected%?20length of stay for members requesting treatments and/or proc?
    edures.

  • Participates in interdepartmental int?
    egration and collaboration to enhance the continuity of care f?
    or members including Behavioral Health and Long Term Care.

  • Maintains department productivity and quality ?
    measures.
  • Attends regular staff meetings.%3?
    C/li>

  • Assists with mentoring of new team members?
    .
  • Completes assigned work plan objectives%2?
    0and projects on a timely basis.
  • Maintain?
    s professional relationships with provider community and internal%?20and external customers.
  • Conducts self in%?20a professional manner at all times.
  • Mai?
    ntains cooperative and effective workplace relationships and adher?
    es to company Code of Conduct.
  • Consults%2?
    0with and refers cases to  medical directors regularly,?
    as necessary.
  • Complies with required wor?
    kplace safety standards.

&?
nbsp;

Knowledge/Skills/Abilities:

  • Demonstrated ability to?
    communicate, problem solve, and work effectively with peopl?
    e.
  • Excellent organizational skill with the%?20ability to manage multiple priorities.
  • Wo?
    rk independently and handle multiple projects simultaneously.

  • Knowledge of applicable state, and federal ?
    regulations.
  • In depth knowledge of Interqua?
    l and other references for length of stay and medical necess?
    ity determinations.
  • Experience with NCQA.%3?
    C/li>

  • Ability to take initiative and see tasks%2?
    0to completion.
  • Computer Literate (Microsof?
    t Office Products).
  • Excellent verbal and%?20written communication skills.
  • Ability to ?
    abide by  policies.
  • Ability to mai?
    ntain attendance to support required quality and quantity of w?
    ork.
  • Maintain confidentiality and comply wi?
    th Health Insurance Portability and Accountability Act (HIPAA)?
    .
  • Skilled at establishing and maintaining%2?
    0positive and effective work relationships with coworkers, clien?
    ts, members, providers and customers.

%?0D

Requirements:

    ?

  • Required Education: Completion of an accredited R?
    egistered Nursing program. (a combination of experience and ?
    education will be considered in lieu of Registered Nursing deg?
    ree). 
  • Required Experience: Minimu?
    m 0-2 years of clinical practice. Preferably hospital nursin?
    g, utilization management, and/or case management. %3?
    C/li>

  • Required Licensure/Certification: Active, ?
    unrestricted State Nursing (RN, LVN, LPN) license in goo?
    d standing.

 

 

Upload your CV/resume or any other relevant file. Max. file size: 300 MB.

Recent Posts