Clinical Care Reviewer II - RN - Nevada WFH - Nevada Resident

Position: Clinical Care Reviewer II - RN - Nevada WFH - Must be Nevada Resident
Location: Nevada
Clinical Care Reviewer II - RN - Nevada WFH - Must be Nevada Resident page is loaded## Clinical Care Reviewer II - RN - Nevada WFH - Must be Nevada Residentlocations:
Nevada WFHtime type:
Full time posted on:
Posted Todayjob requisition :
R10884
*
* 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 Care Source Management Group line of business, as well as monitoring the delivery of healthcare services in a cost effective manner.
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* Essential Functions:

*** Complete prospective, concurrent 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 Care Source Medical Directors when clinical criterial is not met or case conference is needed/appropriate
* Maintain knowledge of state and federal regulations governing Care Source, State Contracts 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 Partners, Care 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 oversight of LPN medical management staff
* Attend medical advisement and State Hearing meetings, as requested
* Assist Team Leader with special projects or research, as requested
* Perform any other job-related 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
* Medicaid/Medicare/Commercial experience is preferred
** Competencies, Knowledge and

Skills:

*** Basic data entry skills and internet utilization skills
* Working knowledge of Microsoft Outlook, Word, and Excel
* Effective oral and written communication skills
* Ability to work independently and within a team environment
* Attention to detail
* Familiarity of the healthcare 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:
*** Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice is required
* MCG Certification is required or must be obtained within six (6) months of hire
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* 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

Care Source 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 latitude required for the role, and other external and internal data when establishing a salary level. In addition to base 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
*** Fostering a Collaborative Workplace Culture
* Cultivate Partnerships
* Develop Self and Others
* Drive Execution
* Influence Others
* Pursue Personal Excellence
* Understand the Business##
** This job description is not all inclusive. Care Source reserves the right to amend this job description at any time. Care Source is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging…