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Clinical Care Coordinator
2 months ago
Position: Clinical Care Coordinator
Location: Remote
Duration: 3+ Months with potential for extension
Role SummaryThis position is focused on supporting Medical Necessity assessments. Candidates should possess prior authorization experience and familiarity with Medicare, Case Utilization, and Care Radius is advantageous. A Registered Nurse (RN) with a minimum of 3 years of clinical experience in both inpatient and outpatient settings is required.
Key Responsibilities- Receive and manage assigned cases across various member services, including inpatient, outpatient, and Durable Medical Equipment (DME).
- Conduct thorough reviews and evaluations of cases to determine medical necessity in accordance with established medical policies, benefits, and regulatory guidelines.
- Ensure completion of tasks within specified timelines while adhering to production, clinical quality, accuracy, and compliance standards.
- Provide necessary notifications to members and/or providers in alignment with regulatory obligations.
- Evaluate cases for potential secondary review by the Medical Director (MD) for denials and facilitate coordination as required.
- May engage in peer-to-peer reviews upon provider requests when members' health conditions do not align with established guidelines.
- Effectively communicate and collaborate with both internal and external clinical and non-clinical staff, including MDs, to ensure seamless coordination of work.
- Accurately document the outcomes of reviews and demonstrate the ability to interpret and analyze clinical data.
- Utilize extensive clinical knowledge to summarize reviews against criteria and guidelines, providing essential information for MDs.
- Registered Nurse (RN) with at least 3 years of clinical experience or Licensed Practical Nurse (LPN) with a minimum of 5 years of clinical experience.
- For roles focused on Behavioral Health, other relevant licensure may be considered, provided the candidate has a minimum of 3 years of clinical experience.
- Must hold and maintain a valid clinical license (NC or compact multi-state licensure) to fulfill the responsibilities of this role.
Select Source International (SSI) is a consulting firm specializing in IT, Health Care, and Engineering Services, established in 1998. Our consultants have consistently delivered exceptional services that have garnered appreciation from clients across various sectors, including Fortune 500 companies and mid-sized enterprises.
