Behavioral Health Care Reviewer II — Care Coordination

CareSource; Dayton (OH); Sur place; USD 63 000 - 100 000; Plein temps

Résumé du poste

CareSource is seeking a Clinical Care Reviewer II – Behavioral Health to handle medical necessity reviews for behavioral health services, support discharge planning, and coordinate care across the member journey.

The role requires RN or social work licensure with relevant clinical experience and a background in utilization management. Join a team focused on compliant care delivery within a collaborative healthcare setting.

Qualifications

• Associates of Science (A.S) in Nursing required.
• Bachelor of Science (B.S) in Social Work required.
• Master's degree in a mental health related field required.
• Three (3) years clinical experience required.
• Utilization Management/Utilization Review experience preferred.
• Medicaid/Medicare/Commercial experience preferred.

Responsabilités

• 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.

Connaissances

Data entry

MS Outlook

MS Word

MS Excel

Communication

Independence

Attention to detail

Grammar/phone etiquette

Time management

Customer service

Decision making

Organization

Change resiliency

Formation

AS Nursing

BS Social Work

MS in mental health field

Three years clinical experience

Utilization Management/Utilization Review experience

Medicaid/Medicare/Commercial experience

Description du poste

CareSource is seeking a Clinical Care Reviewer II – Behavioral Health to handle medical necessity reviews for behavioral health services, support discharge planning, and coordinate care across the member journey.

The role requires RN or social work licensure with relevant clinical experience and a background in utilization management. Join a team focused on compliant care delivery within a collaborative healthcare setting.