Care Review Clinician II

Lancesoft; Long Beach (CA); Remote; USD 63,000 - 65,000; Full time

Benefits offered by this job

Medical Insurance—4 options

Dental Insurance

Vision Insurance

401k Contributions

Critical Illness Insurance

Voluntary Life Insurance

Accident Insurance

Job summary

LanceSoft is seeking a Healthcare - Care Review Clinician II for a remote role in the United States. The position involves medical necessity reviews and prior authorization work for outpatient services, with training and after-training Saturday shifts.

Requirements include 3+ years in health plan or IPA prior authorization and a CA RN or LVN license. Travel to client offices or hospitals may be required as state plans vary.

Qualifications

• 3+ years experience in Health Plan or IPA performing prior authorization review for OUTPATIENT.
• CA RN OR LVN license.

Responsibilities

• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
• Conducts prior authorization reviews to determine financial responsibility for client Healthcare and its members.
• Processes requests within required timelines.
• Refers appropriate prior authorization requests to Medical Directors.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote client Care Model
• Adheres to UM policies and procedures.

Skills

Prior authorization

Education

CA RN or LVN license

Job description

Job Tittle: Healthcare - Care Review Clinician II

Location: Remote Pay Range: $45.37 - $47.37 Duration: 3+ Months Shift Timing: 6 weeks training M-Friday 8: 00am to 5: 00pm PST After training - Alternating Saturdays. Saturday shift is 6am to 2: 30pm PST.

Job Description:

Day to Day Responsibilities: Medical necessity clinical review or services requiring prior authorization

Must Have Requirements:

3+ years experience Health Plan or IPA performing prior authorization review for OUTPATIENT. CA RN OR LVN license Knowledge/Skills/Abilities

• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
• Conducts prior authorization reviews to determine financial responsibility for client Healthcare and its members.
• Processes requests within required timelines.
• Refers appropriate prior authorization requests to Medical Directors.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote client Care Model
• Adheres to UM policies and procedures.
• Occasional travel to other client offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

MUST have 3+ years of Outpatient experience in prior authorization. CA RN OR LVN license

Employee Benefits:

At LanceSoft, full-time regular employees who work a minimum of 30 hours a week or more are entitled to the following benefits:

• Four options of medical Insurance
• Dental and Vision Insurance
• 401k Contributions
• Critical Illness Insurance
• Voluntary Permanent Life Insurance
• Accident Insurance
• Other Employee Perks LanceSoft is a certified Minority Business Enterprise (MBE) and an equal opportunity employer.

We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. LanceSoft makes hiring decisions based solely on qualifications, merit, and business needs at the time.