Job description
Job Summary:
Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services) and care coordination for members.
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.
Requirements
- • Associates of Science (A.S) in Nursing required or
• Bachelor of Science (B.S) in Social Work required or
• Master's degree in a mental health related field (Psychology, Counseling Psychology, Marriage or Family Therapy) required
• Three (3) years clinical experience required
• Utilization Management/Utilization Review experience preferred
• Medicaid/Medicare/Commercial experience preferred
Competencies, Knowledge and Skills:
• Proficient data entry skills and ability to navigate clinical platforms successfully
• Working knowledge of Microsoft Outlook, Word, and Excel
• Effective oral and written communication skills
• Ability to work independently and within a team environment
• Attention to detail
• Proper grammar usage and phone etiquette
• Time management and prioritization skills
• Customer service oriented
• Decision making/problem solving skills
• Strong organizational skills
• Change resiliency
Licensure and Certification:
• Current, unrestricted Registered Nurse (RN) Licensure, Licensed Social Worker (LSW, Licensed Clinical Social Worker (LCSW), Licensed Independent Clinical Social Worker (LICSW), Associate Clinical Social Worker (ACSW), Licensed Mental Health Counselor (LMHC), Licensed Professional Counselor (LPC), Licensed Marriage & Family Therapist (LMFT) or Licensed Mental Health Practitioner (LMHP) required
• MCG Certification is required or must be obtained within six (6) months of hire required
Working Conditions:
• General office environment; may be required to sit or stand for extended periods of time
• Travel is not typically required
$62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Hourly
Organization Level Competencies
- Fostering a Collaborative Workplace Culture
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
About CareSource
CareSource is a managed care organization that hires nurses for remote triage and clinical roles. As a Triage Nurse, you would assess and triage calls from members across all age groups and health statuses using evidence-based guidelines, manage behavioral health crises, educate patients about their conditions, and direct them to appropriate levels of care while documenting in multiple computer systems. The organization also hires Nurse Practitioners for virtual medical control positions to provide acute care decision-making and treatment for patients seen through mobile integrated healthcare services, working with paramedics and EMTs via telehealth technologies.
