Clinical Care Reviewer

Requirements

• Two years of experience in managed care quality assurance or utilization review.
• RN must have two years of experience in an acute care hospital.
• Position Summary:
• Principal Accountabilities:
• Evaluates clinical information submitted by providers against plan review criteria and benefit guidelines.
• Utilizes clinical information to determine if criteria for medical necessity and benefit guidelines are met.
• Utilizes professional judgment to determine if additional information is required, then follows through to obtain additional information prior to making a decision.
• Documents all pertinent case information and dispositions for approvals and denials. Refers all cases failing to meet interqual medical necessity criteria to Medical Director for review and final determination.
• Communicates with providers to initiate/coordinate outpatient services/discharge planning needs for members.
• Acts as a liaison to assure services are provided in the least restrictive, most cost effective and clinically appropriate setting.
• Works with the Utilization Management Manager, the Medical Director and providers to ensure that complete medical information is available to allow utilization management decisions to be made within
• The Plan's standards for decision making.
• Identifies potential members who may benefit from case management services and facilitates referral to the program.
• Identifies and resolves any problems that could interfere with provider's continuity and coordination of care of members and refers unresolved problems to Manager.
• Creates and maintains monthly reports on inpatient activities.
• Performs other related duties and projects as assigned.
• Adheres to ACFC policies and procedures.
• Supports and carries out our Mission & Values.
• ***********************************************************************************************************************
• Best Regards,
• Tissa George
• Mobile: 770-702-0597
• FABERGENT INC
• MUST have Bachelors or Assosciates degree in Nursing or any other related filed.
• Also must have Active Iowa RN license or LPN
• All your information will be kept confidential according to EEO guidelines.

Additional Information

Greetings from Fabergent, Kindly let me know if you are currently available in the job market Feel free to browse across through an opening below which matches your profile Please respond with your updated profile if interested Clinical Care Reviewer Interview type: Phone +face 2 face Location: Des Moines, IA Duration: 3 months Required Skills: - 3 to 5 years or more experience in a related clinical setting - Active Iowa RN license or LPN - UM Experience / Waiver Knowledge (Home and community based) Position Qualifications/Requirements: Education and Training: Associates RN degree required, Bachelor's degree preferred.

Your Match

How well this role fits your profile.

Company Intel

What employees say

Worked at Fabergent? Share your experience