Care Review Clinician II

Job Title: Care Review Clinician II
Location: Fully Remote (Must be licensed in WA state, preferably West Coast)
Duration: 6 Months + (Possibility of Extension)

Pay Rate: $47.13/hr. on W2
 
Must-Have Requirements:

• Utilization Management experience
• Behavioral Health background

 
Licensure Required:

• Licensed in the state of Washington as one of the following:
  • Social Worker
  • Mental Health Counselor
  • Marriage and Family Therapist
  • Psychiatric Nurse

 
Work Hours:

• 9:00 AM – 5:00 PM PST, Monday through Friday
• Possibly Tuesday through Saturday
• Must work PST hours

 
Summary:
Works with the Utilization Management team, primarily responsible for inpatient medical necessity/utilization reviews and other utilization management activities. Ensures members receive the right care, at the right place, and at the right time. Performs daily reviews and evaluations of members requiring hospitalization or procedures, providing prior authorizations and concurrent reviews. Assesses services to ensure optimum outcomes, cost-effectiveness, and compliance with state and federal regulations.
 
Essential Functions:

• Provide concurrent review and prior authorizations according to Client policies.
• Identify benefits, eligibility, and expected length of stay for members requesting treatments or procedures.
• Collaborate across departments to enhance continuity of care, including Behavioral Health and Long Term Care.
• Maintain productivity and quality measures within the department.
• Attend staff meetings and assist in mentoring new team members.
• Complete assigned projects and objectives timely.
• Maintain professional relationships with providers and internal/external customers.
• Conduct self professionally at all times.
• Adhere to company Code of Conduct and workplace safety standards.
• Consult and refer cases to Client medical directors as necessary.

 
Knowledge, Skills, and Abilities:

• Strong communication, problem-solving, and teamwork skills.
• Excellent organizational skills with ability to manage multiple priorities independently.
• Knowledge of state and federal regulations, NCQA standards, and Interqual guidelines for medical necessity and length of stay.
• Computer literate with Microsoft Office proficiency.
• Strong verbal and written communication skills.
• Commitment to confidentiality and HIPAA compliance.
• Ability to maintain positive work relationships with coworkers, clients, members, providers, and customers.

 
Required Education:

• Completion of an accredited Registered Nursing program (or a combination of experience and education may be considered).

 
Required Experience:

• Minimum 2-4 years clinical practice experience.
• Preferably hospital nursing, utilization management, and/or case management experience.

 
Required Licensure/Certification:

• Active, unrestricted State Nursing license (RN, LVN, or LPN) in good standing.