Care Review Clinician II

Job Title: Care Review Clinician II

Job Location: 100% Remote in WA

Job Duration: 3 months+ contract + (Possibilities of Extension)

Shift: 8-5 Mon - Fri PST

Pay rate: $47.14/hr. on W2

Summary:

· Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing client Healthcare members with the right care at the right place at the right time.

· Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review.

· Assesses services for Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

Essential Functions:

· Provides concurrent review and prior authorizations (as needed) according to client policy for Client members as part of the Utilization Management team.

· Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.

· Participates in interdepartmental integration and collaboration to enhance the continuity of care for Client members including Behavioral Health and Long-Term Care.

· Maintains department productivity and quality measures.

· Attends regular staff meetings.

· Assists with mentoring of new team members.

· Completes assigned work plan objectives and projects on a timely basis.

· Maintains professional relationships with provider community and internal and external customers.

· Conducts self in a professional manner at all times.

· Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct. Consults with and refers cases to Client medical directors regularly, as necessary.

· Complies with required workplace safety standards.

Knowledge/Skills/Abilities:

·         Demonstrated ability to communicate, problem solve, and work effectively with people.

·         Excellent organizational skill with the ability to manage multiple priorities.

·         Work independently and handle multiple projects simultaneously.

·         Knowledge of applicable state, and federal regulations.

·         In depth knowledge of InterQual and other references for length of stay and medical necessity determinations.

·         Experience with NCQA.

·         Ability to take initiative and see tasks to completion.

·         Computer Literate (Microsoft Office Products).

·         Excellent verbal and written communication skills.

·         Ability to abide by Client’s policies.

·         Ability to maintain attendance to support required quality and quantity of work.

·         Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).

·         Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers.

Required Education/Certification(s) :

Licensed in the state of WA as Social Worker, Mental Health Counselor, Marriage Family Therapist, or Psychiatric Nurse.

Top Skills Required:

Utilization Management Experience, Behavioral Health Background