What are the responsibilities and job description for the Care Review Clinician II (68223) position at Professional Management Enterprises?
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
- 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.
