Care Review Clinician I (69983)

Professional Management Enterprises
United States
Apr 23, 2025
Care Review Clinician Iwork with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing members'ultimate care. This position is FULLY REMOTE. Schedule M-F 8am-6pm EST. Day to Day Responsibilities: Conduct UM reviews using the medical management system within department policy and procedure KNOWLEDGE/SKILLS/ABILITIES * Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review * Analyzes clinical service requests from members or providers against evidence based clinical guidelines. * Identifies appropriate benefits and eligibility for requested treatments and/or procedures. * Conducts prior authorization reviews to determine financial responsibility for members. * Processes requests within required timelines. * Refers appropriate prior authorization requests to Medical Directors. * Requests additional information from members or providers in consistent and efficient manner. * Makes appropriate referrals to other clinical programs. * Collaborates with multidisciplinary teams to promote Care Model * Adheres to UM policies and procedures. Must Have Skills: at least 1 year UM experience in a HP setting LPN or RN The ability to work remote in a high pace/high demand environment. The ability to complete 15-20 authorization in a day Previous experience using QNXT/UMK2/PEGA preferred MCG Experience preferred. Required Years of Experience: 1 Required Licensure / Education: RN/LPN;Behavioral Health Clinician, LMSW, LMHC