[Hiring] Care Review Clinician I @Integrated Resources

Role Description

Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing members with the right care at the right place at the right time.

• Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review.
• Assesses services for Client Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

Qualifications

• Completion of an accredited Registered Nursing program (a combination of experience and education will be considered in lieu of Registered Nursing degree).

Requirements

• BH experience required.
• Must have an Ohio RN or Compact State License.
• Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.
• Minimum 0-2 years of clinical practice, preferably in hospital nursing, utilization management, and/or case management.

Benefits

• Monday thru Friday 8:00AM to 5:00PM EST (Rotating weekends and Holiday schedules are required for this position).
• Once orientation period has finished, Employee may be eligible for an alternative work schedule.

Essential Functions

• Provides concurrent review and prior authorizations (as needed) according to Client policy for Client members as part of the Utilization Management team.
• Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
• Participates in interdepartmental integration and collaboration to enhance the continuity of care for Client members including Behavioral Health and Long Term Care.
• Maintains department productivity and quality measures.
• Attends regular staff meetings.
• Assists with mentoring of new team members.
• Completes assigned work plan objectives and projects on a timely basis.
• Maintains professional relationships with provider community and internal and external customers.
• Conducts self in a professional manner at all times.
• Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct.
• Consults with and refers cases to Client medical directors regularly, as necessary.
• Complies with required workplace safety standards.

Knowledge/Skills/Abilities

• Demonstrated ability to communicate, problem solve, and work effectively with people.
• Excellent organizational skill with the ability to manage multiple priorities.
• Work independently and handle multiple projects simultaneously.
• Knowledge of applicable state and federal regulations.
• In-depth knowledge of Interqual and other references for length of stay and medical necessity determinations.
• Experience with NCQA.
• Ability to take initiative and see tasks to completion.
• Computer literate (Microsoft Office Products).
• Excellent verbal and written communication skills.
• Ability to abide by Clients policies.
• Ability to maintain attendance to support required quality and quantity of work.
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
• Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers, and customers.