Healthcare - Care Review Clinician I
Company: APN Consulting, Inc
Location: New York
Posted on: May 4, 2024
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Job Description:
Job Title: Healthcare - Care Review Clinician I Location: Remote
( Must possess NY State Nursing License ) Duration: 6 Months Job
Description: Work Location (i.e., onsite or remote based): Remote
based but candidates can be located anywhere in the US but must be
licensed in NY StateWill now accept RN's! Reason for Job Request: 1
CRC left last year and last week received approval to fill
positionAlso SWH has a jump in enrollment (900 enrollees for March)
with a steady growth over several months. Will require 1 additional
monitor. Job Description: All UM standard/ expedited Inpatient,
Outpatient and Custodial Care clinical reviews for MLTC members.
Must Have Skills: Must have experience in UM, experience with
Turnaround Timeframes, good with computer systems and be able to
learn a new system, have done clinical reviews and processed
denials and partial denial determinations, know MCG and can use it,
case presentation for medical reviews, know Medicaid/ Medicare
guidelinesBi-lingual Spanish, Bengali or Mandarin- PREFERRED! NOT
Mandatory. Day to Day Responsibilities: All UM standard Inpatient,
Outpatient and Custodial Care processes and workflows for any
requests, verbal notifications for denials/partial denials to both
member and provider, participation in IDTs, personal queue
management and clinical reviews. Required Years of Experience: At
least 1-2 years experience in UM. Required Licensure / Education:
Licensure required is a NY State License Practical Nurse or
Registered Nurse -LPN NY & NY RN Summary: Works with the
Utilization Management team primarily responsible for inpatient
medical necessity/utilization review and other utilization
management activities aimed at providing members with the right
care at the right place at the right timeProvides daily review and
evaluation of members that require hospitalization and/or
procedures providing prior authorizations and/or concurrent
reviewAssesses services for Client Members to ensure optimum
outcomes, cost effectiveness and compliance with all state and
federal regulations and guidelines
Essential Functions: Provides concurrent review and prior
authorizations (as needed) according to Client policy for Client
members as part of the Utilization Management teamIdentifies
appropriate benefits, eligibility, and expected length of stay for
members requesting treatments and/or proceduresParticipates in
interdepartmental integration and collaboration to enhance the
continuity of care for Client members including Behavioral Health
and Long Term CareMaintains department productivity and quality
measuresAttends regular staff meetingsAssists with mentoring of new
team membersCompletes assigned work plan objectives and projects on
a timely basisMaintains professional relationships with provider
community and internal and external customersConducts self in a
professional manner at all timesMaintains cooperative and effective
workplace relationships and adheres to company Code of
ConductConsults with and refers cases to Client medical directors
regularly, as necessaryComplies with required workplace safety
standards
Knowledge/Skills/Abilities: Demonstrated ability to communicate,
problem solve, and work effectively with peopleExcellent
organizational skill with the ability to manage multiple
prioritiesWork independently and handle multiple projects
simultaneouslyKnowledge of applicable state, and federal
regulationsIn depth knowledge of Interqual and other references for
length of stay and medical necessity determinationsExperience with
NCQAAbility to take initiative and see tasks to completionComputer
Literate (Microsoft Office Products)Excellent verbal and written
communication skillsAbility to abide by Clients policiesAbility to
maintain attendance to support required quality and quantity of
workMaintain confidentiality and comply with Health Insurance
Portability and Accountability Act (HIPAA)Skilled at establishing
and maintaining positive and effective work relationships with
coworkers, clients, members, providers and customers
Required Education: Completion of an accredited Registered Nursing
program(a combination of experience and education will be
considered in lieu of Registered Nursing degree)
Required Experience: Minimum 0-2 years of clinical
practicePreferably hospital nursing, utilization management, and/or
case management
Required Licensure/Certification: Active, unrestricted State
Nursing (RN, LVN, LPN) license in good standing
Keywords: APN Consulting, Inc, North Bergen , Healthcare - Care Review Clinician I, Healthcare , New York, New Jersey
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