Care Review Clinician I - LVN/RN in California ONLY

Remote Care Review Clinician I – CA 11.24

100% remote

What is the typical schedule/shift going to be (i.e., 8am – 5pm)? 8-1700 or 830 – 1730 or 9-1800 PST ***

Must be RN or LVN licensed in California

Job Description

Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

Must Have Skills:

• Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.

• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.

• Conducts inpatient reviews to determine financial responsibility for Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.

• Processes requests within required timelines.

• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.

• Requests additional information from members or providers in consistent and efficient manner.

• Makes appropriate referrals to other clinical programs.

• Collaborates with multidisciplinary teams to promote Care Model.

• Adheres to UM policies and procedures.

Day to Day Responsibilities

• Clearing discharges using UMK2 and EMR access

• Admission and continued stay reviews

• Processing NON-PAR and Eligibility Reviews

• Completing reviews per Sharp/SCRIPPS/DIGNITY PROCESS • Internal Reconsideration reviews

• Peer to Peer Follow Up

• Reconsideration Follow Up • Processing denials and requesting letters

• Reviewing DOFR for financial responsibility

• Disenrollment for members that expire

• Following Hospital Assignment Grid / MD Coverage List Requirements:

Required Years of Experience: 1 Year Med Surg Required Licensure / Education: CA RN/LVN License

For immediate consideration be sure your resume is updated to reflect your coordinating skills for this role.

Kimberly Cameron, PHR

HR & Lead, MCO Talent Acquisition Team

773-881-5743 / [email protected]