Clinical Care Reviewer II-BH - MSL - Must be RN

Job Summary:

Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services) and care coordination for members.

Essential Functions:

Complete prospective, concurrent and retrospective review of Behavioral Health services
Identify, document, communication and coordinate care engaging collaborative care partners to facilitation transition to an appropriate level of care
Engage with medical director when additional clinical expertise if needed
Maintain knowledge of state and federal regulations, including State Contracts and Provider Agreements, benefits, and accreditation standards
Identify and refer quality issues to Quality Improvement
Identify and refer appropriate members for Care Management
Provide guidance to non-clinical staff
Provide guidance and support to LPN staff
Attend medical advisement and State Hearing meetings, as requested
Assist Team Leader with special projects or research, as requested
Perform any other job related duties as requested.

Education and Experience:

Associates of Science (A.S) in Nursing required or
Bachelor of Science (B.S) in Social Work required
Three (3) years clinical experience required
Utilization Management/Utilization Review experience preferred
Medicaid/Medicare/Commercial experience preferred

Competencies, Knowledge and Skills:

Proficient data entry skills and ability to navigate clinical platforms successfully
Working knowledge of Microsoft Outlook, Word, and Excel
Effective oral and written communication skills
Ability to work independently and within a team environment
Attention to detail
Proper grammar usage and phone etiquette
Time management and prioritization skills
Customer service oriented
Decision making/problem solving skills
Strong organizational skills
Change resiliency

Licensure and Certification:

Current, unrestricted Registered Nurse (RN) Licensure or Licensed Social Worker (LSW) required
MCG Certification is required or must be obtained within six (6) months of hire required

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time
Travel is not typically required

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. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Hourly

Organization Level Competencies

Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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