About the position
RepuCare is a certified woman-owned business and Women Business Enterprise (WBE) currently partnered with a large managed care organization seeking a Clinical Care Reviewer registered nurse for a REMOTE, 6 MONTH CONTRACT position. The ideal candidate will possess nursing experience in utilization review, including prior authorization and concurrent review. This position is specifically for candidates residing in the state of Indiana. As a Clinical Care Reviewer II, you will be responsible for processing medical necessity reviews to determine the appropriateness of authorization for healthcare services. This includes assisting with discharge planning activities such as durable medical equipment (DME) and home health services, as well as care coordination for members enrolled in a specific line of business. You will also monitor the delivery of healthcare services to ensure they are provided in a cost-effective manner. Your essential functions will include completing prospective, concurrent, and retrospective reviews of various healthcare services, coordinating care, and facilitating timely discharge to appropriate levels of care. You will refer cases to Medical Directors when clinical criteria are not met and maintain knowledge of relevant state and federal regulations. Additionally, you will identify quality issues and refer members for Care Management, document and communicate with Health Partners, and provide guidance to non-clinical medical management staff. You may also assist with oversight of LPN and LISW medical management staff and attend medical advisement and State Hearing meetings as requested. Special projects or research may also be assigned by the Team Leader.
Responsibilities
Complete prospective, concurrent and retrospective review of acute inpatient admissions, post acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment.
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Coordinate care and facilitate discharge to an appropriate level of care in a timely and cost-effective manner.
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Refer cases to Medical Directors when clinical criteria is not met or case conference is needed/appropriate.
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Maintain knowledge of state and federal regulations governing Company, State Contracts and Provider Agreements, benefits, and accreditation standards.
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Identify and refer quality issues to Quality Improvement.
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Identify and refer appropriate members for Care Management.
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Document, identify and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care.
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Provide guidance to non-clinical medical management staff.
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Provide guidance to and assist with oversight of LPN and LISW medical management staff.
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Attend medical advisement and State Hearing meetings, as requested.
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Assist Team Leader with special projects or research, as requested.
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Perform any other job-related instructions, as requested.
Requirements
Completion of an accredited registered nursing (RN) degree program is required.
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Minimum of three (3) years clinical experience is required.
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Med/surgical, emergency acute clinical care or home health experience is preferred.
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Medical management experience is preferred.
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Medicaid/Medicare/Commercial experience is preferred.
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Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice is required.
Nice-to-haves
BLS Certification (Preferred)
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Nursing experience of 1 year (Preferred)
Benefits
401(k)
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Dental insurance
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Health insurance
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Paid time off
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Vision insurance
