Care Review Clinician I

1 week ago


Los Angeles, United States Professional Management Enterprises Full time
Care Review Clinician I Nurse(LVN or RN)MUSTbe licensed in California.
Strong inpatient and outpatient medical and hospital analytical experience is needed. Excellent computer multi-tasking skills and good productivity is essential for this fast-paced role.
Strong computer skills, being able to toggle back and forth and use multiple databases.
Good analytical thought process is important to be successful in this role, this is a metric-based environment. Fully remote. The schedule is 8:00am-5:00pm or 8:30am-5:30pm or 9:00am-6:00pm PST.

Must Have Skills:
* Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
* Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
* Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
* Conducts inpatient reviews to determine financial responsibility for members. May also perform prior authorization reviews and/or related duties as needed.
* Processes requests within required timelines.
* Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
* Requests additional information from members or providers in consistent and efficient manner.
* Makes appropriate referrals to other clinical programs.
* Adheres to UM policies and procedures.

Day to Day Responsibilities:
* Clearing discharges using UMK2 and EMR access
* Admission and continued stay reviews
* Processing NON PAR and Eligibility Reviews
* Completing reviews per Sharp/SCRIPPS/DIGNITY PROCESS
* Internal Reconsideration reviews
* Peer to Peer Follow Up
* Reconsideration Follow Up
* Processing denials and requesting letters
* Reviewing DOFR for financial responsibility
* Disenrollment for members that expire
* Following Hospital Assignment Grid / MD Coverage List

Required Years of Experience: 1 Year Med Surg
Required Licensure / Education: CA RN/LVN License


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