What are the responsibilities and job description for the Care Review Clinician II (68223) position at Professional Management Enterprises, Inc.?
Care Review Clinician I to review prior authorizations for outpatient services for medical necessity for New Mexico Medicaid and process member and provider benefit determination notices. MUST reside in the state of Mexico. This position is FULLY REMOTE. Schedule M-F 8:30am-5:00pm.
KNOWLEDGE/SKILLS/ABILITIES
JOB QUALIFICATIONS
Required Education: Graduate from an Accredited School of Nursing.
Required Experience: 3 years hospital acute care/medical experience.
Required License, Certification, Association Active, unrestricted State Registered Nursing (RN) license in good standing.
KNOWLEDGE/SKILLS/ABILITIES
- 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 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.
JOB QUALIFICATIONS
Required Education: Graduate from an Accredited School of Nursing.
Required Experience: 3 years hospital acute care/medical experience.
Required License, Certification, Association Active, unrestricted State Registered Nursing (RN) license in good standing.
