Care Review Clinician I (IL)

Job Title: Care Review Clinician
Schedule: Full-time, Remote (Must work CST hours)
Pay Rate: $37.98/hr (W2)
Location Requirement: Must hold an active Illinois RN license
Must have inpatient medical and inpatient behavioral health experience.
Work Hours: 8:00 AM – 5:00 PM CST or 9:00 AM – 6:00 PM CST
Work Days: May include weekends/holidays

Job Description:
This care review clinician position is for the inpatient team.
One remote position – must work CST hours; schedule likely 8am to 5pm CST or 9am to 6pm CST; may need to work weekends/holidays at times and may need to work until 6pm CST at times.
Must have an Illinois license – must be an RN.
Must have 2+ years of experience.
Must have inpatient medical and inpatient behavioral health experience.

Job Summary
Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential.
HCS 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.

KNOWLEDGE/SKILLS/ABILITIES
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 *** 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.

JOB QUALIFICATIONS
Completion of an accredited Registered Nurse (RN).

Required Experience
1-3 years of acute hospital medical/behavioral health experience
1+ year of Utilization Management

Required License, Certification, Association
Active, unrestricted State Registered Nursing (RN) license in good standing
State Specific Requirements:
IL Qualifications: Licensed within the state of Illinois RN
Familiarity with Inpatient Medical, Behavioral Health, and Utilization Management
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 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
Preferred, but not required: Familiarity with medical necessity criteria (i.e. MCG criteria, ASAM criteria)

Day to Day Responsibilities:
Review clinical received from facilities for Client members who have been admitted for Inpatient Medical-Surgical or Inpatient Behavioral Health.
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/Collaborates with Client Medical Directors on appropriate inpatient medical and / or inpatient behavioral health requests.
Collaborate with multidisciplinary team members to ensure member needs are being addressed
Attend weekly team meetings
Monthly 1:1s with supervisor