What are the responsibilities and job description for the Care Review Clinician I (66168) position at Professional Management Enterprises?
Care Review Clinician I(RN or LPN) to work with the Utilization Management team primarily responsible for inpatient medical necessity / utilization review and other utilization management activities. This position is FULLY remote, but
- MUST reside in New Mexico . The work schedule will be M-F 8 : 30am-5 : 00pm MST. Some weekends may be required.
Essential Functions :
Provides concurrent review and prior authorizations (as needed) according to policy for members as part of the Utilization Management team.
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. Knowledge / Skills / Abilities :
Demonstrated ability to communicate, problem solve, and work effectively with people.
Excellent organizational skill with the ability to manage multiple priorities.
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. Required Education
Required Education : Nursing Degree with RN or LPN licensure
Required Experience
3-5 years Utilization Management experience in a HP setting. Minimum 0-2 years of clinical practice. Preferably hospital nursing, utilization management, and / or case management.
Required License
Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.
