What are the responsibilities and job description for the Care Review Clinician position at Professional Management Enterprises?
Care Review Clinician I (RN or LSW) to work with the HCS team to deliver care across the continuum. This position is FULLY remote, but ***MUST reside in Illinois. The work schedule will be M-F 8:00am-5:00pm CST.
ESSENTIAL FUNCTIONS:
Work 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. Support HCS staff work to ensure that patients 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.
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 providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs, such as Case Management.
• Collaborates with multidisciplinary teams to promote Care Model.
• Adheres to UM policies and procedures.
REQUIRED EDUCTION:
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 Behavioral Health hospital acute care/medical experience.
REQUIRED LICENSE:
• Active, unrestricted State license in good standing, such as RN, LCSW, LPCC/LCPC or LMFT.
Salary : $42
