Offer summary

Qualifications:

Registered Nurse (RN) licensure or Bachelor's Degree in Social Work., Minimum of three years of clinical experience., Knowledge of healthcare regulations and care coordination., Familiarity with evidence-based care systems like MCG or ASAM..

Key responsibilities:

Review medical necessity for behavioral health services.

Coordinate discharge planning and care transitions.

Refer cases to Medical Directors when criteria are not met.

Support quality improvement and care management activities.

Job description

Job Summary:

Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services) and care coordination for members enrolled with a CareSource Management Group line of business, as well as monitoring the delivery of behavioral healthcare services in a cost effective manner.

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 CareSource Medical Directors when clinical criterial is not met or case conference is needed/appropriate
Maintain knowledge of state and federal regulations governing CareSource, 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 and LISW 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 or Bachelor’s Degree in Social Work is required
Minimum of three (3) years clinical experience is required
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
Familiar with Evidence Based Care systems such as MCG or ASAM
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 or Licensed Social Worker (LSW) in state(s) of practice is required
MCG Certification is required or must be obtained within 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

CareSource 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