Clinical Care Reviewer II-Post Acute

Job Summary:Clinical Care Reviewer II - Post-Acute is responsible for conducting medical necessity reviews to determine the appropriateness of authorization for post-acute health care services including Skilled Nursing Facilities (SNF), Nursing Facilities (NF), Long Term Acute Care Hospitals (LTACH), and Inpatient Rehabilitation Facilities (IRF). This role assists with discharge planning activities (i.e. DME, home health services) and care coordination for members enrolled with a CareSource Management Group line of business, and monitors the delivery of healthcare services to ensure they are provided in a cost-effective manner.Essential Functions:Conduct prospective, concurrent, and retrospective review of post-acute admissions and related services, including outpatient services provided in the post-acute setting according to established processesComplete clinical reviews for new and continued stays in post-acute services; assist in facilitating timely and cost-effective member discharges to the appropriate level of careRefer cases to CareSource Medical Directors when clinical criteria are not met or when a need for a case conference is identifiedMaintain knowledge of state and federal regulations governing CareSource, including state contracts, provider agreements, CareSource policies and procedures, benefits, and accreditation standardsIdentify and refer quality issues to the Quality Improvement departmentIdentify and refer members receiving post-acute services to Care Management according to established processes, escalating new or changing member needs as necessaryDocument member discharge planning needs to support coordinated care and communicate with providers, care managers/care coordinators, discharge planners, CareSource Provider Relations, and other external stakeholders to support discharge planning activitiesParticipate in required inter-rater reliability (IRR) audits to ensure consistency and accuracy in reviewsAttend and participate in department huddles, team meetings, and all staff meetings; review meeting minutes and/or other collateral when unable to attendProvide guidance and support to non-clinical utilization management staff as neededAttend medical advisement and State Hearing meetings as requestedAssist Team Leader with special projects or research tasks as requestedPerform any other job-related duties as assignedEducation and Experience:Completion of an accredited registered nursing (RN) degree program is requiredMinimum of three (3) years clinical experience is requiredMed/surgical, emergency, acute clinical care or Post Acute Care experience is preferredUtilization Management/Utilization Review experience is preferredMedicaid/Medicare/Commercial experience is preferredCompetencies, Knowledge and Skills:Basic data entry skills and internet utilization skillsWorking knowledge of Microsoft Outlook, Word, and ExcelEffective oral and written communication skillsAbility to work independently and within a team environmentAttention to detailFamiliarity of the healthcare fieldProper grammar usage and phone etiquetteTime management and prioritization skillsCustomer service orientedDecision making/problem solving skillsStrong organizational skillsChange resiliencyLicensure and Certification:Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice is requiredMCG Certification is required or must be obtained within six (6) months of hireWorking Conditions:General office environment; may be required to sit or stand for extended periods of timeAvailability to work scheduled weekend and holiday hours to ensure continuous departmental coverage and support for reviews throughout the year, including all 365 daysCompensation Range:$61,500.00 - $98,400.00 CareSource takes into consideratio

Created: 2025-12-05