Care Review Clinician I (IL)

Work Schedule:

• Must be able to work within CST or EST time zones.
• Variable hours Sunday-Sunday with potential to work until 6pm CST.

Job Summary:

• Client 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.

Day to Day Responsibilities:

• 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.
• 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).

Education:

• Completion of an accredited Registered Nurse (RN).

Experience:

• 1-3 years Medical/Surgical acute hospital care experience.
• 2+ years MCO and / or UM Experience preferred.
• 1+ year Utilization Management experience.

Required License, Certification, Association:

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

Knowledge, Skills and Abilities:

• Familiarity with Inpatient Medical Necessity and Utilization Management.
• 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 a Products 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 *** 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.

Additional Skills:

• 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.