Clinical Care Reviewer II - MA RN License required - Direct UM experience strongly preferred!
Core
Process medical necessity reviews for authorization of healthcare services, assist with discharge planning, and coordinate care for members.
Role type
Senior Utilization Management Registered Nurse
Builds
Authorization decisions for acute inpatient, post-acute, outpatient, and homecare services
Domain
Healthcare / Utilization Management
Required skills
Medical necessity review, discharge planning, care coordination, state/federal regulations knowledge, quality issue identification, care management referral, guidance to non-clinical staff, LPN supervision, medical advisement participation, special projects support
Preferred skills
Med/surgical, emergency acute, or home health experience, Utilization Management/Utilization Review experience, Medicaid/Medicare/Commercial experience
Technologies
Clinical platforms, Microsoft Outlook, Word, Excel
Responsibilities
Complete prospective, concurrent, and retrospective reviews; identify and document care needs; engage collaborative care partners; maintain knowledge of regulations; refer quality issues; refer members for care management; provide guidance to staff; attend medical advisement and State Hearing meetings; assist Team Leader with projects
Seniority
Mid-level, hands-on IC