Care Review Clinician I (IL)

Job Title: Care Review Clinician I (IL)
Location: Remote (Illinois Licensed)
Pay Rate: $37.98/hr (W2) 
Schedule: CST hours (8AM–5PM or 9AM–6PM), with occasional weekends/holidays and extended hours as needed
Must have an Illinois RN license.
Must have 2+ years of experience with prior authorization and MCO/UM experience.

Job Description:
These care review clinician positions are for the prior authorization team.
Four remote positions – must work CST hours; schedule likely 8 a.m. to 5 p.m. CST or 9 a.m. to 6 p.m. CST. May need to work weekends/holidays at times and may need to work until 6 p.m. CST at times.
Must have an Illinois RN license.
Must have 2+ years of experience with prior authorization and MCO/UM 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 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 and eligibility for requested treatments and/or procedures.
Conducts prior authorization reviews to determine financial responsibility for *** and its members.
Processes requests within required timelines.
Refers appropriate prior authorization requests to Medical Directors.
Requests additional information from members or providers in consistent and efficient manner.
Makes appropriate referrals to other clinical programs.
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 hospital or medical clinic experience.
1+ year Prior Authorization or 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.
Must Have Skills: Familiarity with Prior Authorization 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, PEGA)

Day to Day Responsibilities:
Assesses 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 and eligibility for requested treatments and/or procedures.
Conducts prior authorization reviews to determine financial responsibility for *** and its members.
Processes requests within required timelines.
Refers appropriate prior authorization requests to Medical Directors.
Requests additional information from members or providers in consistent and efficient manner.
Makes appropriate referrals to other clinical programs.
Collaborates with multidisciplinary teams to promote Client Care Model
Adheres to UM policies and procedures.

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