Care Review Clinician I
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. - 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.
%?3Cli>Identifies appropriate benefits, eligibility, and expected%?20length of stay for members requesting treatments and/or proc?
edures.
&?
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.
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