Clinical Utilization & Care Coordination Specialist II

CareSource; Little Rock (AR); On-site; USD 37,000 - 59,000; Full time

Job summary

CareSource is seeking a Complex Population Service Determination Specialist II in Little Rock, AR. The role focuses on processing medical necessity and HCBS services for authorizations and supports discharge planning and care coordination for members within CareSource Management Group lines of business.

Responsibilities include prior and retro-authorizations, collaboration with Medical Directors, and ensuring compliance with state and federal regs.

Qualifications

• Nursing degree or BS in health care or equivalent experience.
• Prior utilization review, case management, BH/SUD/IDD/HCBS/Waiver experience preferred.
• Experience with Medicaid/Medicare/Managed Care is preferred.

Responsibilities

• Compare PCSP to service requests for accuracy and need.
• Conduct front and back end reviews of services approved in Cite Auto Auth.
• Coordinate with provider network and Care Coordination on clinical quality audits and reviews.
• Lead transition and discharge planning for high-need members (I/DD and BH).
• Authorize BH/SUD/IDD/HCBS/Waiver PASSE services and manage retro-authorization reviews.
• Collaborate with Medical Directors and Care Coordinators to ensure appropriate services.
• Familiar with Evidence Based Care systems (MCG, ASAM, HCBS guidelines).
• Maintain knowledge of state/federal regulations, contracts, and NCQA standards.

Skills

Communication

Independent work

Healthcare knowledge

Data entry

Team collaboration

Education

Nursing degree or health-care bachelor

Tools

MS Word

MS Excel

MS Access

Job description

CareSource is seeking a Complex Population Service Determination Specialist II in Little Rock, AR. The role focuses on processing medical necessity and HCBS services for authorizations and supports discharge planning and care coordination for members within CareSource Management Group lines of business.

Responsibilities include prior and retro-authorizations, collaboration with Medical Directors, and ensuring compliance with state and federal regs.