Care Review Clinician - Remote

Overview

A Managed Care Organization (MCO) is seeking an experienced Nurse (LVN or RN) licensed and located in California to join the team as a Care Review Clinician. This position supports the Continuity of Care (COC) and Community Support Teams and is responsible for providing clinical reviews to determine if requests meet COC or Community Support criteria.

In Short

• Serve as a clinical reviewer to determine if requests meet COC criteria or Community Support criteria.
• Provide concurrent review and prior authorizations as part of the Utilization Management team.
• Review inpatient and outpatient services, ensuring the services provided are cost-effective and meet the appropriate clinical standards.
• Complete authorizations for medical services, collaborate with medical directors, and follow UM processes.
• Communicate with providers, including completing phone calls when necessary to ensure care coordination.
• Work in a fast-paced, metric-based environment, ensuring compliance with state and federal guidelines.

Requirements

• Experience: 3-5 years of clinical experience, ideally in both inpatient and outpatient settings. Experience in utilization review or case management is a plus.
• Education/Licensure: Licensed Vocational Nurse (LVN) or Registered Nurse (RN) with an active, unrestricted California license.
• Skills: Strong computer skills, ability to multitask and toggle between databases, excellent analytical skills, and proficiency in managing large volumes of data and tasks.
• Knowledge: Familiarity with UM processes, InterQual or other medical necessity review tools, and NCQA standards.

Benefits

• Competitive pay at $40.00 per hour.
• Comprehensive benefits package is offered.