Healthcare - Care Review Clinician I - APN Consulting : Job Details

Job Title: Healthcare - Care Review Clinician I Location: Remote ( Must possess NY State Nursing License ) Duration: 6 Months Job Description: Work Location (i.e., onsite or remote based): Remote based but candidates can be located anywhere in the US but must be licensed in NY StateWill now accept RN's! Reason for Job Request: 1 CRC left last year and last week received approval to fill positionAlso SWH has a jump in enrollment (900 enrollees for March) with a steady growth over several months. Will require 1 additional monitor. Job Description: All UM standard/ expedited Inpatient, Outpatient and Custodial Care clinical reviews for MLTC members. Must Have Skills: Must have experience in UM, experience with Turnaround Timeframes, good with computer systems and be able to learn a new system, have done clinical reviews and processed denials and partial denial determinations, know MCG and can use it, case presentation for medical reviews, know Medicaid/ Medicare guidelinesBi-lingual Spanish, Bengali or Mandarin- PREFERRED! NOT Mandatory. Day to Day Responsibilities: All UM standard Inpatient, Outpatient and Custodial Care processes and workflows for any requests, verbal notifications for denials/partial denials to both member and provider, participation in IDTs, personal queue management and clinical reviews. Required Years of Experience: At least 1-2 years experience in UM. Required Licensure / Education: Licensure required is a NY State License Practical Nurse or Registered Nurse -LPN NY & NY RN Summary: Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing *** members with the right care at the right place at the right timeProvides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent reviewAssesses services for Client 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 teamIdentifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or proceduresParticipates in interdepartmental integration and collaboration to enhance the continuity of care for Client members including Behavioral Health and Long Term CareMaintains department productivity and quality measuresAttends regular staff meetingsAssists with mentoring of new team membersCompletes assigned work plan objectives and projects on a timely basisMaintains professional relationships with provider community and internal and external customersConducts self in a professional manner at all timesMaintains cooperative and effective workplace relationships and adheres to company Code of ConductConsults with and refers cases to Client medical directors regularly, as necessaryComplies with required workplace safety standards Knowledge/Skills/Abilities: Demonstrated ability to communicate, problem solve, and work effectively with peopleExcellent organizational skill with the ability to manage multiple prioritiesWork independently and handle multiple projects simultaneouslyKnowledge of applicable state, and federal regulationsIn depth knowledge of Interqual and other references for length of stay and medical necessity determinationsExperience with NCQAAbility to take initiative and see tasks to completionComputer Literate (Microsoft Office Products)Excellent verbal and written communication skillsAbility to abide by Clients policiesAbility to maintain attendance to support required quality and quantity of workMaintain 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: Completion of an accredited Registered Nursing program(a combination of experience and education will be considered in lieu of Registered Nursing degree) Required Experience: Minimum 0-2 years of clinical practicePreferably hospital nursing, utilization management, and/or case management Required Licensure/Certification: Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing