Healthcare - Care Review Clinician I

Utilization Management Team Support

Reason for Job Request: Additional resource support for HCS-UM team to support going live in new UM system NO TIME OFF REQUESTS WILL BE PERMITTED 5/5/25-5/30/25 due to system implementation and training. Start date is 5/19 and will be in the thick of the implementation during that time. 8am-6pm EST or CST. 40 hours with weekend rotation. Candidates can be located in any 1 of the following 15 states-AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY (outside greater-NYC), OH, TX, UT, WA (outside greater-Seattle), WI

Knowledge/Skills/Abilities:

• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
• Conducts prior authorization reviews to determine financial responsibility for Healthcare and its members.
• Processes requests within required timelines.
• Refers appropriate prior authorization requests to Medical Directors.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote Care Model
• Adheres to UM policies and procedures.

Must Have Skills:

• At least 1 year UM experience in a Client setting LPN or RN
• The ability to work remote in a high pace/high demand environment.
• The ability to complete 15-20 authorization in a day
• Previous experience working for Healthcare using QNXT/UMK2/PEGA preferred
• MCG Experience preferred.

Day to Day Responsibilities:

• Complete 15-20 authorizations per day
• Review Prior auth/Inpatient/Skilled Nursing requests for medical necessity using State/Policy or MCG criteria

Required Years of Experience: 1

Required Licensure / Education: RN/LPN

Summary: Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing Healthcare members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for Healthcare 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 policy for members as part of the Utilization Management team.
• Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
• Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and Long Term Care.
• Maintains department productivity and quality measures.
• Attends regular staff meetings.
• Assists with mentoring of new team members.
• Completes assigned work plan objectives and projects on a timely basis.
• Maintains professional relationships with provider community and internal and external customers.
• Conducts self in a professional manner at all times.
• Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct.
• Consults with and refers cases to medical directors regularly, as necessary.
• Complies with required workplace safety standards.

Knowledge/Skills/Abilities:

• Demonstrated ability to communicate, problem solve, and work effectively with people.
• Excellent organizational skill with the ability to manage multiple priorities.
• Work independently and handle multiple projects simultaneously.
• Knowledge of applicable state, and federal regulations.
• In depth knowledge of Interqual and other references for length of stay and medical necessity determinations.
• Experience with NCQA.
• Ability to take initiative and see tasks to completion.
• Computer Literate (Microsoft Office Products).
• Excellent verbal and written communication skills.
• Ability to abide by policies.
• Ability to maintain attendance to support required quality and quantity of work.
• Maintain 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 practice. Preferably hospital nursing, utilization management, and/or case management.

Required Licensure/Certification: Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.