Care Review Clinician

Louisville, KentuckySkills : RN,hospital nursing,nursing,LVN,lpn,Care Review Clinician,care review,clinicianDescription :

• Candidate must have an active, unrestricted Kentucky or Compact RN or LPN license to qualify for the role
• Candidate must be located in Louisville, Kentucky to qualify for the role
• Candidate must have Utilization Management/ Prior Authorization experience to qualify for the role
• 100% remote position, Travel may be required, Temp to Hire possibility

• Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review.
• Assesses services for 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 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.
• Completes assigned work plan objectives and projects on a timely basis.
• Maintains professional relationships with provider community and internal and external customers.

• 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.
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).

• 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.