Care Review Clinician I

Care Review Clinician I works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. This position is remote, but candidates MUST reside in the state of ILLINOIS. The work schedule will be 8am-5pm. Prefer Saturday worker with Wednesday or Monday being the preferred day off during the week.

KNOWLEDGE/SKILLS/ABILITIES
Must have experience in UM, experience with turnaround timeframes, good with computer systems and be able to learn a new system. MUST have experience with conducting clinical reviews and processed denials and partial denial determinations.  MCG criteria knowledge is a plus, case presentation for medical reviews. MUST have experience with reviewing for Medicaid/ MLTC members. MUST know Medicaid/ Medicare guidelines. May also perform prior authorization reviews and/or related duties as needed.

Required Education
Required Education: Nursing Degree with RN licensure OR
Master's Degree in Social Work, Psychology, or other Behavioral Health field with clinical licensure (i.e. LCSW, LCPC)
Required Experience
3 years hospital acute care/medical experience.
Required License
Active, unrestricted IL State license in good standing, such as RN, LCSW, LPCC/LCPC or LMFT.