About the Role
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 line of business, as well as monitoring the delivery of 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 Medical Directors when clinical criterial is not met or case conference is needed/appropriate
Maintain knowledge of state and federal regulations governing Company, 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
Requirements
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
Medical management experience is preferred
Medicaid/Medicare/Commercial experience is preferred
Licensure and Certification:
Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice is required. *Must be licensed in Indiana
About the Company
RepuCare is a certified woman-owned business and Women Business Enterprise (WBE). We are currently partnered with a large managed care organization looking for a Clinical Care Reviewer registered nurse for a REMOTE, 6 MONTH CONTRACT. The ideal candidate has nursing experience in utilization review, including prior authorization and concurrent review.