Clinical Care Reviewer

Fabergent

Des Moines (IA)

On-site

USD 70,000 - 85,000

Full time

14 days+

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Job summary

A healthcare management company based in Des Moines is seeking a Clinical Care Reviewer for a 3-month position. The role requires evaluating clinical information for medical necessity and benefit guidelines, documenting case information, and ensuring continuity of care. Candidates must have an active Iowa RN license or LPN, along with experience in clinical settings and quality assurance. This position offers competitive pay and a collaborative work environment.

Qualifications

3 to 5 years of experience in a related clinical setting.
Two years of experience in managed care quality assurance or utilization review.

Responsibilities

Conduct timely reviews of all requests for services to meet medical necessity criteria.
Evaluate clinical information against plan review criteria and benefit guidelines.
Document pertinent case information and dispositions for approvals and denials.

Skills

Clinical experience

Active Iowa RN license or LPN

UM Experience / Waiver Knowledge

Education

Associates RN degree

Bachelor’s degree preferred

Job description

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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.

Experience

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

Responsible for conducting timely reviews of all requests for services required to meet medical necessity criteria to include reviewing pre-certification for outpatient and inpatient services. Applying criteria to inpatient admissions and performing concurrent review functions, identifying discharge planning needs and referral of members to case management.

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.