Pay Range: $39/hr -$42/hr

Benefits:
The Company offers the following benefits for this position, subject to applicable eligibility requirements: medical insurance, dental insurance, vision insurance, 401(k) retirement plan, life insurance, long-term disability insurance, short-term disability insurance, paid parking/public transportation, (paid time , paid sick and safe time , hours of paid vacation time, weeks of paid parental leave, paid holidays annually - AS Applicable)

About the Role

• The Care Review Clinician, Prior Authorization, is responsible for collaborating with physicians and multidisciplinary team members to develop and implement a comprehensive plan of care for patients from admission through discharge.
• This role involves assessing members' care needs, developing treatment plans, and ensuring quality care is provided to achieve desired patient outcomes.

Responsibilities

• Identify appropriate benefits, eligibility, and expected length of stay for requested treatments and procedures.
• Analyze clinical service requests against evidence-based clinical guidelines.
• Process requests within required timelines and refer cases to Medical Directors as needed.
• Request additional information from members or providers efficiently.
• Make appropriate referrals to other clinical programs.
• Collaborate with multidisciplinary teams to promote the Care Model.
• Adhere to Utilization Management (UM) policies and procedures.
• Mentor new Care Review Clinicians during the orientation period and sign off on core competencies.
• Model new programs, techniques, and trainings with peers.
• Coordinate medical services/appointments post-discharge and make necessary community resource referrals.

Education Qualification

• Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse program.

Required Skills

• 1-3 years of clinical practice experience.
• RN or LVN/LPN license to practice in Texas without restrictions.
• Proficiency in MS products such as Teams, Outlook, and Word.
• Experience in Utilization Review or working in home health.
• Ability to perform medical necessity reviews for prior authorizations for both inpatient and outpatient services for Medicaid members in Texas.
• Strong communication and collaboration skills.