UM RN Care Review Clinician

Job Description

Job Description

AltaStaff is a staffing agency currently looking for a  Care Review Clinician I to work with our Managed Care Client!

Pay Rate: $40 - 42.00 hourly

Schedule: Monday-Friday 9am-5:30pm CST, Rotating Saturday 7-11am CST, Rotating Holidays

***This is a fully remote role but candidates must have a valid RN license in Illinois***

Position Purpose: Care Review Clinician works with the Utilization Management team primarily responsible for medical necessity/utilization review aimed at providing members with the right care.

• Assess and analyze clinical service requests (e.g., surgeries, outpatient therapies, DME) using evidence-based MCP/MCG criteria.

• Verify member benefits and eligibility and Process prior authorization determinations within regulatory timelines

• Collaborate with multidisciplinary teams

• Completes/reviews Authorizations, reviewing faxes that can be 50-100 pages long

• Will be expected to manage 25-30 cases successfully daily.

• Should be able to quickly and accurately determine whether the criteria meet medical necessity.

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

• Assesses services for Molina Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and

• guidelines.

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

• Additional duties assigned

Education/Experience:  

• RN license in IL required

• Must have 2+ years clinical practice experience (hospital, case management, utilization management)

• Must have 1-3+ years of hospital or medical clinic, utilization review

• Must have 2-3 years of Prior Authorization OR Med-Surg experience; Familiarity with Inpatient Medical Necessity

• Must have solid experience within a clinical setting as RN’s must be able to use their knowledge to extrapolate key information during the authorization process

If you've applied and would like to view your application status, please visit: 

AltaStaff is an Equal Employment Opportunity Employer. We provide equal employment opportunities to all qualified applicants for employment without regard to age, race, color, creed, religion, sex, marital status, national origin, ancestry, citizenship, disability, veteran status, sexual orientation, or any other protected status, in accordance with applicable federal, state, and local laws.

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