Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities and care coordination for members, as well as monitoring the delivery of healthcare services.
Compensation Range:
$62,700.00 - $100,400.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance.
- Complete prospective, concurrent and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment
- Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care
- Engage with medical director when additional clinical expertise if needed
- Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards
- Identify and refer quality issues to Quality Improvement
- Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program required
- Nice to have: Med/surgical experience
- Nice to have: Emergency acute clinical care experience
- Nice to have: Home health experience
- Nice to have: Utilization Management/Utilization Review experience
Patient Services AssociateMoses / Weitzman Health System · New London, US