Job posting has expired

Care Review Clinician II (69306)

Professional Management Enterprises
United States, Washington, Seattle
Apr 01, 2025
Care Review Clinician IIto work with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities.This position is fully remote. To qualify youMUSThave an active, unrestricted WASHINGTON STATE licensure (RN, LPN, LCSW, LPCC or LMFT). The work schedule is Monday-Friday, 9-5 PST or possibly Tuesday-Saturday PST. Essential Functions: Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for members to ensure optimum outcomes and compliance with all state and federal regulations and guidelines. Provides concurrent review and prior authorizations. Identifies appropriate benefits, eligibility, and expected length of stay for members requesting 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. Knowledge/Skills/Abilities: Demonstrated ability to communicate, problem solve, and work effectively with people. 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. Computer Literate (Microsoft Office Products). Excellent verbal and written communication skills. Required Education: Completion of an accredited Registered Nursing program. Required Experience:Minimum 2-4 years of clinical practice. Preferably hospital nursing, utilization management, and/or case management. Required Licensure/Certification: Active, unrestricted State Nursing (RN or LVN) WA license in good standing.