Care Review Clinician I

Job Title: Care Review Clinician I

Location: 100% Remote in IL

Duration: 3 Months (Possible extension)

Pay rate: $37.97/hr on W2

Job Description:

· Inpatient Medical Reviewer Team

· Fully remote – Must be able to work within CST or EST time zones.

· Variable hours Saturday-Sunday with potential to work until 6pm CST

Summary:

• The Care Review Clinician is responsible for reviewing inpatient services to ensure optimal outcomes, cost-effectiveness, and compliance with state and federal regulations. You will work closely with members, providers, and multidisciplinary teams to coordinate integrated care and support improved member health outcomes.

Day-to-Day Responsibilities:

• Review clinical received from facilities for Client members who have been admitted for inpatient medical.
• Assess inpatient services to determine appropriateness and medical necessity. Analyze clinical service requests using evidence-based clinical guidelines.
• Confirm member eligibility and expected length of stay.
• Collaborate with & outreach facilities to ensure authorization information is up to date and clinical information and discharge information are received in a timely manner.
• Refers appropriate Inpatient Medical requests to Medical Directors for medical necessity reviews.
• Collaborate with multidisciplinary team members (i.e. Case Management) to ensure member needs are being addressed.
• Attend weekly team meetings.
• Monthly 1:1s with supervisor.

Required Qualifications:

• Must be a Registered Nurse (RN) licensed in the state of Illinois.
• 1-3 years Medical/Surgical acute hospital care experience.
• 1+ year of Utilization Management experience.
• Familiarity with Inpatient Medical Necessity and Utilization Management.
• Flexibility, Dependability, Reliability, Good time Management, Organized.
• Attention to detail – especially important for both reviews being completed but also to ensure HIPAA compliance when communicating determinations and other information with facilities.
• Ability to multi-task, focus and work in a fast-paced environment.
• Ability to work efficiently to ensure meeting strict deadlines per our state requirements/contract.
• Proficient in the use of Microsoft Office applications.
• Ability to work with multiple monitors and in multiple applications to complete reviews.
• Highly recommended, but not required: Familiarity with medical necessity criteria (i.e. MCG criteria).

Required Experience:

• Medical/surgical acute hospital care experience.
• Utilization Management (UM) experience.

Preferred Experience:

• 2+ years Managed Care Organization (MCO) and / or Utilization Management (UM) experience preferred.