Clinical Care Reviewer II - RN - BH FOCUS - Compact Licensed

CareSource; United States; Remote; USD 41,000 - 66,000; Full time

Job summary

CareSource is seeking a Clinical Care Reviewer II – Behavioral Health to process medical necessity reviews for behavioral health services. The role supports discharge planning, care coordination, and collaboration with care partners across transitions in care.

Requires RN or social work licensure, 3+ years of clinical experience, and MCg certification within 6 months. Knowledge of state/federal regulations and utilization review is preferred.

Qualifications

• RN licensure (unrestricted) required
• LSW/LCSW/LICSW/ACSW/LMHC/LPC/LMFT/LMHP licensure required
• MCG Certification required or within 6 months of hire
• Minimum 3 years clinical experience
• Utilization Management/Utilization Review experience preferred
• Medicaid/Medicare/Commercial experience preferred

Responsibilities

• Prospective, concurrent and retrospective review of Behavioral Health services
• Coordinate care with collaborative care partners for transition to appropriate level of care
• Engage medical director when clinical expertise is needed
• Maintain knowledge of state and federal regulations and contracts
• Identify and refer quality issues to Quality Improvement
• Direct care management referrals as appropriate
• Provide guidance to non-clinical staff and to LPN staff
• Attend medical advisement and State Hearing meetings as requested
• Assist Team Leader with special projects or research
• Perform other job-related duties as requested

Skills

Data entry

Microsoft Outlook

Microsoft Word

Microsoft Excel

Communication skills

Independent worker

Time management

Customer service

Decision making

Organizational skills

Change resiliency

Education

AS in Nursing

BS in Social Work

MS in mental health field

Tools

Clinical platforms

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.

Essential Functions:

• 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.

Education and Experience:

• 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

Compensation Range:

$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.

Compensation Type (hourly/salary):

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.

Brand= CareSource Originally posted on Himalayas