Care Review Clinician I

AltaStaff is a staffing agency currently looking for a Care Review Clinician I to work with our Managed Care Client!

Pay Rate: $40 - $42 hourly

Schedule: 8-430pm or 8-5pm EST

***This is a fully remote role but candidates must be licensed in Virginia***

Summary: This role will review provider service requests for applicable medical necessity and processing results. Will assesses outpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Works to ensure patient 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.

Responsibilities:

• Completes/reviews Outpatient Authorizations, reviewing faxes that can be 50-100 pages long

• 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 outpatient reviews to determine financial responsibility for the client 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.

• Occasional travel to other offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

POSITION QUALIFICATIONS

• Must have RN license in Virginia

• Must have 2 years of clinical practice experience (hospital, case management, utilization management)

• Must have 1-2 years Utilization Management experience with Outpatient Authorizations, especially DME and therapy

• Experience with Virginia Medicaid or other State Medicaid highly preferred

• Must have experience working in a high production capacity

Work Environment Requirements:

• Must be able to to lift at least 30lbs

• Must be able to stand or sit for prolonged periods (75% of the time)

• Private Secured Internet Connection

• Must confirm work environment is safe and secure for work in handling private and sensitive information.

• Constantly operates a computer and other office equipment

• Constantly works indoors in a secluded safe space

• Must have High-speed internet access 25 MBPS minimum; 50 MBPS minimum preferred

AltaStaff is an Equal Employment Opportunity Employer. We provide equal employment opportunities to all qualified applicants for employment without regard to age, race, color, creed, religion, sex, marital status, national origin, ancestry, citizenship, disability, veteran status, sexual orientation, or any other protected status, in accordance with applicable federal, state, and local laws.

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