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CareSource · 2 hours ago

Clinical Care Reviewer II - Behavioral Health

United States

Full-time

Remote

Mid Level

3+ years exp

CareSource is a healthcare organization dedicated to providing quality care and services. The Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for behavioral health care services and assisting with care coordination for members.

Health CareMedicalNon Profit

Comp. & Benefits

Responsibilities

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

Qualification

Registered Nurse (RN) LicensureLicensed Social Worker (LSW)MCG CertificationUtilization Management experienceMedicaid/Medicare experienceProficient data entryMicrosoft Office skillsCustomer service orientedChange resiliencyEffective communicationAttention to detailTime managementDecision making skillsOrganizational skills