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CARE REVIEW CLINICIAN I

Job Title: Care Review Clinician I

Company Name: Confidential

Employment Type: Full-time

Location: Bothell, Washington, United States

Department: Case Management

Shift Hours/Days: 8:00 – 5:00 Monday thru Friday

Degree Required: Active, unrestricted State LVN or LPN in good standin

Years Experience: Minimum 1 year of clinical practice.

Preferred Experience: Managed Care Utilization Management

Date Posted: September 19, 2012

JobSummary
Works with the integrated Care Access and Monitoring team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review and other utilization management activities aimed at providing healthcare members with the right care at the right place at the right time. Provides daily review and evaluation of members requiring hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

Duties and Responsibilities
• Provides prior authorizations according to policy and monitors services for members as part of the Care Access and Monitoring team.
• Identifies appropriate benefits, eligibility, and expected length of stay for members requesting new treatments and/or procedures.
• Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and Long Term Care.
• Maintains department productivity and quality measures.
• Attends regular staff meetings.
• Assists with mentoring of new team members.
• Completes assigned work plan objectives and projects on a timely basis.
• Maintains professional relationships with provider community and internal and external customers.
• Conducts self in a professional manner at all times.
• Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct.
• Consults with and refers cases to medical directors regularly, as necessary.
• Complies with required workplace safety standards.

Knowledge, Skills and Abilities
• Demonstrated ability to communicate, problem solve, and work effectively with people.
• Excellent organizational skill with the ability to manage multiple priorities.
• Work independently and handle multiple projects simultaneously.
• Knowledge of applicable state, and federal regulations.
• In depth knowledge of Interqual and other references for length of stay and medical necessity determinations.
• Experience with NCQA.
• Ability to take initiative and see tasks to completion.
• Computer Literate (Microsoft Office Products).
• Excellent verbal and written communication skills.
• Ability to abide by policies.
• Ability to maintain attendance to support required quality and quantity of work.
• Maintain 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.

PeopleSolutions Healthcare Staffing, Inc. is proud to be an Equal Opportunity Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, disability, sexual orientation, ancestry, marital or veteran status.

About PeopleSolutions Healthcare Staffing, Inc.:

PeopleSolutions Healthcare Staffing thrives at serving the healthcare industry. We work diligently to provide outstanding customer service and earn the loyalty of each of our clients. PeopleSolutions identifies the most qualified candidates; people we believe can make a positive contribution in our client's work environment. Whether you're a company seeking temporary staffing, temp-to- hire or direct-hire employees, PeopleSolutions will work to meet your business needs and exceed your customer service expectations.

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