Care Review Clinician I

Job Title: Care Review Clinician I
Location: 100% Remote
Duration: 3 Months+ (temp to hire)

Schedule: Wednesday - Sunday 8 – 5 pm PST

Pay Range: $43 - $44/hr. on W2

Description:

· The Care Review Clinician is responsible for performing utilization management (UM) reviews, including prior authorization of outpatient services, to ensure medical necessity, appropriate level of care, and compliance with regulatory and organizational guidelines.

· The clinician will review clinical documentation, apply evidence-based criteria, and collaborate with providers to facilitate timely and appropriate care for members.

· This role supports Client’s commitment to quality, cost-effective care and regulatory compliance within the California health plan.

Must Have Skills:

· Knowledge of California delegation requirements

· Strong understanding of utilization management processes

· Experience with prior authorization review (outpatient preferred)

· Ability to apply clinical guidelines (e.g. MEDICAID, MCG)

Day to Day Responsibilities:

·         Process outpatient prior authorization referrals

·         Review clinical documentation for medical necessity

·         Apply established UM criteria and guidelines

·         Communicate with providers for additional clinical information

·         Ensure compliance with state, federal, and Client policies

·         Document determinations accurately and timely

Required Years of Experience:

·         Active, unrestricted California RN or LVN license required

·         Minimum of 3 years of clinical experience in utilization management