Clinical Care Reviewer Utilization Management Jobs

Demonstrated experience in utilization management, discharge planning, or transfer coordination.

Previous case management experience preferred.

Must be able to work in a Labor/Management partnership environment.

Bachelors degree in nursing or health related field OR four (4) years of experience in a directly related field.

High School Diploma or General Education Development (GED) required.

Knowledge of Nurse Practice Act, TJC, and other federal/state/local regulations.

3+ years combined clinical and utilization management experience

Experience with utilization management platform preferred

Knowledge, Skills & Abilities Required:

Ensures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policy

3+ years' experience working in a health plan preferred

Strong collaboration and negotiation skills

3+ years clinical practice experience, e.g., hospital or behavioral health setting,

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

Experience working in the Louisiana Medicaid Behavioral Health system *strongly preferred*.

Utilization review experience strongly preferred.

Licensed addiction counselor (LAC) and/or substance use disorder treatment experience preferred

Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

3+ years clinical practice experience, e.g., hospital or behavioral health setting,

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

Experience working in the Louisiana Medicaid Behavioral Health system *strongly preferred*.

Utilization review experience strongly preferred.

Licensed addiction counselor (LAC) and/or substance use disorder treatment experience preferred

Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

3+ years clinical practice experience, e.g., hospital or behavioral health setting,

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

Experience working in the Louisiana Medicaid Behavioral Health system *strongly preferred*.

Utilization review experience strongly preferred.

Licensed addiction counselor (LAC) and/or substance use disorder treatment experience preferred

Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.

Submits appropriate documentation/clinical information in enterprise platform systems record keeping and documentation requirements.

Maintains awareness and complies with Plan CHC authorization timeliness standards based on DHS/NCQA requirements.

Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).

Verifies and documents Participant eligibility for services.

Accessing and applying Medical Guidelines for decision making prior to Medical Director/Physician Advisor referral.

Do you value care management and quality improvement?

Are you an experienced Clinical Reviewer looking for a new challenge?

Performs ongoing reassessment of review process to offer opportunities for improvement and/or change.

Active unrestricted RN applicable State and/or Compact State clinical license per contract requirements.

Knowledge of current NCQA/URAC standards strongly preferred.

Medical record abstracting skills required.

Utilization of clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.

Utilization of clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members

Identification of members who may benefit from care management programs and facilitation of the referral

1+ year(s) of utilization management experience within a managed care organization

Identification of opportunities to promote quality effectiveness of healthcare services and benefit utilization

5+ years of clinical experience as a Registered Nurse

Maintain the prescribed workload including work queue management, process oversight and committee responsibilities.

Education, Training, Experience, Certification and Licensure:

Participating in Revenue Cycle functions including work queue and account management, monitoring metrics, and attendance at meetings.

Participate in interdisciplinary meetings regarding UR and denials management, including retroactive chart reviews, data collection, and process development.

Maintain BLS/CPR certification. Maintain other certifications appropriate to field.

Career advancement to senior leadership roles such as Manager, Director or Administrative roles.

Demonstrate knowledge of utilization management including experience managing prior-authorization and concurrent review.

Case management certification highly preferred.

3+ years of managed care and/or case management experience.

We invite you to join our Scripps Health Utilization Management team of Care Managers.

Knowledge of Medicare and Commercial health plans.

Ability to independently utilize critical thinking skills, nursing judgement and decision-making skills.

Medical management experience is preferred

Time management and prioritization skills

Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards

Identify and refer appropriate members for Care Management

Provide guidance to non-clinical medical management staff

Provide guidance to and assist with oversight of LPN and LISW medical management staff

Case Management Certification (CCM) preferred within first year of eligibility.

Prior Utilization Management experience is preferred.

Completes Utilization Management for assigned patients with a minimum of 25-30 reviews per day.

Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets.

Has three to five years of experience working in a hospital.

Demonstrates strong critical thinking and problem-solving skills.

Knowledge and skill in the use of computer software applications for drafting documents, data management, and tracking.

Minimum one (1) year experience with supervisory/ management experience

HMO, managed care, PPO, Utilization Management experience

Manages the time and attendance of supervised colleagues.

Promotes UM and CDI as a key aspect of patient care, providing education to staff and medical team.

Minimum three (3) year experience with Milliman and/ or InterQual

Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.

Submits appropriate documentation/clinical information in enterprise platform systems record keeping and documentation requirements.

Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).

Verifies and documents Participant eligibility for services.

Accesses and applies Medical Necessity Guidelines for decision making.

Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)

Applies clinical knowledge to work with facilities and providers for care coordination.

Educates the member about plan benefits and contracted physicians, facilities and healthcare providers.

Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications.

Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.

Job Family: Medical and Clinical

Date Posted: Apr 20, 2023

You have experience working remotely and are self-motivated.

You hold strong knowledge of Medicare PDGM and 1-2 years process experience strongly desired.

Develops/maintains a working knowledge of all CareCentrix services/guidelines/policies and accesses CareCentrix contract information, including the terms of the contract as appropriate.

You manage multiple tasks, are detail oriented, responsive, and demonstrate independent thought and critical thinking.

You possess strong computer skills, including the ability to navigate multiple internal systems, programs and external sites to conduct reviews.

You have a minimum of 1-2 years prior authorization experience for Medicare or Medicare Advantage Home Health required.

Exposure or experience with clinical operations and/or utilization management

Previous experience in strategy consulting, commercial, business strategy, clinical and operational area and/or related roles

Experience leading cross-functional group of leaders/teams and initiatives

Strong communication skills both verbal and written, with ability to flex to different audiences, including senior leadership

Proven skills influencing others and a track record of success leading through ambiguity

Proven organization, planning and prioritization skills to collaborate with multiple enterprise departments and stakeholders; ability to execute within deadlines

3+ years combined clinical and utilization management experience

Experience with utilization management platform preferred

Knowledge, Skills & Abilities Required:

Ensures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policy

3+ years' experience working in a health plan preferred

Strong collaboration and negotiation skills

Performs and remains knowledgeable in all workflow and timeliness requirements for all areas in Utilization Management

Strong knowledge base of health care resources, ideally with managed care experience.

Monitors staff work assignments and makes appropriate adjustments based on staffing levels, staff experience, and number/request types of authorizations/appeals received.

Assist the LTSS UM Manager in providing oversight for operational reporting compliance

Assesses candidates and ensures that optimal qualifications are met as a member of the department’s interview team.

Reviews quality audits and shares audit results in a timely manner with associates, providing necessary education and counseling to improve performance.

Experience performing utilization management reviews (prior authorization and concurrent reviews) in a managed care organization.

3 or more years of experience in a related clinical setting as a Registered Nurse.

Strong written and verbal communication skills.

Associate’s Degree required; Bachelor’s Degree preferred.

Current unrestricted North Carolina or compact Registered Nurse license required.

Proficiency utilizing MS Office and electronic medical record and documentation programs.