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    Care Review Clinician I - New York, United States - Professional Management Enterprises

    Professional Management Enterprises
    Professional Management Enterprises New York, United States

    3 weeks ago

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    Description

    Job Description

    Job Description

    Seeking a Care Review Clinician (RN, LPN or LVN - MUSTBE LICENSED IN NY STATE ) to work with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing Healthcare members with the right care. The position is remote, but candidates MUSTBE LICENSED IN NY STATE . The work schedule is M-F 8am-5pm.

    Essential Functions

    • Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review.
    • Assesses services for Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
    • Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
    • Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and Long-Term Care.

    Knowledge/Skills/Abilities:

    • Demonstrated ability to communicate, problem solve, and work effectively with people.
    • Excellent organizational skill with the ability to manage multiple priorities.
    • Work independently and handle multiple projects simultaneously.
    • Knowledge of applicable state, and federal regulations.
    • In-depth knowledge of Interqual and other references for length of stay and medical necessity determinations.
    • Experience with NCQA.
    • Computer Literate (Microsoft Office Products).

    Required Education:

    • Completion of an accredited Registered Nursing program. (a combination of experience and education will be considered in lieu of a Registered Nursing degree).

    Required Experience:

    • Minimum 0-2 years of clinical practice. Preferably hospital nursing, utilization management, and/or case management.

    Required Licensure/Certification:

    • Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.
    Company DescriptionProfessional Management Enterprises is a minority and veteran owned business that partners with major healthcare providers to find quality employees and thrives on helping people find positions that exceeds their expectations.

    Company Description

    Professional Management Enterprises is a minority and veteran owned business that partners with major healthcare providers to find quality employees and thrives on helping people find positions that exceeds their expectations.
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