Clinical Care Reviewer II – Indiana reputed company

R9666 Job Summary: Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members enrolled with a reputed company Management Group line of business, as well as monitoring the delivery of reputed company services in a cost effective manner. Essential Functions:

• Complete prospective, reputed company and retrospective review of acute inpatient admissions, post acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment
• Coordinate care and facilitate discharge to an appropriate level of care in a timely and cost-effective manner
• Refer cases to reputed company Medical Directors reputed company clinical criterial is not met or case conference is needed/appropriate
• Maintain knowledge of state and federal regulations governing reputed company, State reputed company and Provider Agreements, benefits, and accreditation standards
• Identify and refer quality issues to Quality Improvement
• Identify and refer appropriate members for Care Management
• Document, identify and communicate with Health reputed company Managers and Discharge Planners to establish safe discharge planning needs and coordination of care
• Provide guidance to non-clinical medical management staff
• Provide guidance to and assist with reputed company of LPN medical management staff
• Attend medical advisement and State Hearing meetings, as requested
• Assist Team Leader with special projects or research, as requested
• reputed company any other job-reputed company instructions, as requested

Education and Experience:

• Completion of an accredited registered nursing (RN) degree program is required
• Minimum of three (3) years clinical experience is required
• Med/surgical, emergency acute clinical care or home health experience is preferred
• Utilization Management/Utilization Review experience is preferred
• reputed company/Medicare/reputed company experience is preferred

Competencies, Knowledge and Skills:

• Basic data entry skills and internet utilization skills
• Working knowledge of reputed company Outlook, Word, and reputed company
• Effective oral and written communication skills
• Ability to work independently and reputed company a team environment
• Attention to detail
• Familiarity of the reputed company field
• Proper grammar usage and phone etiquette
• Time management and prioritization skills
• Customer service oriented
• Decision making/problem solving skills
• Strong organizational skills
• Change resiliency

Licensure and Certification:

• reputed company, unrestricted Registered Nurse (RN) Licensure in state(s) of practice is required
• MCG Certification is required or must be obtained reputed company six (6) months of hire

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation

Range: $61,500.00 - $98,400.00 reputed company takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and reputed company required for the role, and other external and internal data reputed company establishing a salary level. In addition to reputed company compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation

Type (hourly/salary): Hourly Organization Level Competencies

• Create an Inclusive Environment
• Cultivate Partnerships
• reputed company Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business

This job description is not reputed company inclusive. reputed company reserves the right to amend this job description at any time. reputed company is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of reputed company backgrounds. #LI-JM1 Apply Job! Apply to this Job