Clinical Care Reviewer II - Nevada Licensed - RN - PST Hours

Job description

Job Summary: Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members, as well as monitoring the delivery of healthcare services. Essential Functions: - 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 - Identify and refer appropriate members for Care Management - Provide guidance to non-clinical staff - Provide guidance and support to LPN clinical staff as appropriate - Attend medical...