Care Review Clinician I (IL)

Job Title: Care Review Clinician I
Location: Chicago, IL (Remote)
Duration: 2-3 Months+ (Possible Extension)
 
Pay Rate: $37.97/hr. on W2
 
Job Description:

• Client Healthcare Services works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including medical-surgical adult and pediatric members .
• Client staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

• Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members or providers aProductst evidence based clinical guidelines.
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
• Conducts inpatient reviews to determine financial responsibility for Client Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.
• Processes requests within required timelines.
• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
• Requests additional information from providers in a consistent and efficient manner.
• Makes appropriate referrals to other clinical programs, such as Case Management.
• Collaborates with multidisciplinary teams to promote Client Care Model.
• Adheres to UM policies and procedures.
• Flexibility.Dependability,Reliability,Good time Management, Organized.
• Attention to detail – especially important for both reviews being completed but also to ensure HIPAA compliance when communicating determinations and other information with facilities
• Ability to multi-task, focus and work in a fast-paced environment
• Ability to work efficiently to ensure meeting strict deadlines per our state requirements/contract
• Proficient in the use of Microsoft Office applications
• Ability to work with multiple monitors and in multiple applications to complete reviews
• Highly Recommended, but not required: Familiarity with medical necessity criteria (i.e. MCG criteria)
• Review clinical received from facilities for Client members who have been admitted for inpatient medical.
• Collaborate with & outreach facilities to ensure authorization information is up to date and clinical information and discharge information are received in a timely manner
• Refers appropriate Inpatient Medical requests to Medical Directors for medical necessity reviews.
• Collaborate with multidisciplinary team members (i.e. Case Management) to ensure member needs are being addressed
• Attend weekly team meetings
• Monthly 1:1s with supervisor

• Completion of an accredited Registered Nurse (RN)

• IL Qualifications: Licensed within the state of Illinois RN
• Familiarity with Inpatient Medical Necessity and Utilization Management
• 2+ years MCO and / or UM Experience preferred
• Active, unrestricted IL State license in good standing, RN.
• 40 hours/week variable hours, some weekends/holidays possible and may need to work until 6:30pm CST.
• None to very little
• Must be able to work within CST or EST time zones.
• Variable hours Sunday-Sunday with potential to work until 6:30pm CST

• 1-3 years Medical/Surgical acute hospital care experience.
• 1+ year Utilization Management experience

• Active, unrestricted IL State Registered Nursing (RN) license in good standing