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- Assesses services for members to ensure optimum outcomes.
- Provides concurrent review and prior authorizations (as needed).
- 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.
- Maintains department productivity and quality measures.
Care Review Clinician II - Indianapolis, United States - Professional Management Enterprises
Description
Seeking a Care Review Clinician (RN, LVN, LPN) to work with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review.This position is fully remote.Available Shifts:
Monday - Friday 8:30am-5:00pm
Sunday to Wednesday 8:00am-5:30pm, Thursday 8:00am-12:00pm
Tuesday - Friday 8:00am-5:30pm, Saturday 8:00am-12:00pm
Essential Functions:
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).
Education:
Completion of an accredited Registered Nursing program.
Required Experience:
Minimum 2-4 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.