Genetic Counselor, Clinical Reviewer
The Cigna Group
Clinical Reviewer II, RN
CareSource
full-time
Posted on:
Location: Ohio • 🇺🇸 United States
Visit company websiteSalary
💰 $61,500 - $98,400 per year
Job Level
Mid-LevelSenior
About the role
- Complete prospective, concurrent and retrospective review of acute inpatient admissions, post acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment
- Coordinate care and facilitate discharge to an appropriate level of care in a timely and cost-effective manner
- Refer cases to CareSource Medical Directors when clinical criterial is not met or case conference is needed/appropriate
- Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards
- Identify and refer quality issues to Quality Improvement
- Identify and refer appropriate members for Care Management
- Document, identify and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care
- Provide guidance to non-clinical medical management staff
- Provide guidance to and assist with oversight of LPN medical management staff
- Attend medical advisement and State Hearing meetings, as requested
- Assist Team Leader with special projects or research, as requested
- Perform any other job-related instructions, as requested
Requirements
- Completion of an accredited registered nursing (RN) degree program is required
- Minimum of three (3) years clinical experience is required
- Med/surgical, emergency acute clinical care or home health experience is preferred
- Utilization Management/Utilization Review experience is preferred
- Medicaid/Medicare/Commercial experience is preferred
- Military affiliation or TRICARE experience is preferred
- Current, unrestricted RN licensure in state(s) of practice is required
- MCG Certification is required or must be obtained within six (6) months of hire
