Care Review Clinician I (IL)

Job Title: Care Review Clinician I (RN Inpatient Medical)
Location: Remote (IL)
Duration: 3 Months

Job Description:
Care Review Clinician, RN Inpatient Medical

Must be able to work within CST or EST time zones.
Variable hours Sunday-Sunday with potential to work until 6pm CST
Requires dual monitors & docking station

Job Description:
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 medical-surgical adult and pediatric members. 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 Medical/Surgical acute hospital care experience.
1+ year Utilization Management experience

Required License, Certification, Association:
Active, unrestricted IL State Registered Nursing (RN) license in good standing

State Specific Requirements:
IL Qualifications: Licensed within the state of Illinois RN
Must Have Skills: Familiarity with Inpatient Medical Necessity 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 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)

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

Required Years of Experience:
2+ years MCO and / or UM Experience preferred
Required Licensure / Education:
Active, unrestricted IL State license in good standing, RN.