• Job Description

  Req#: 25-80734
  
  Job Profile Summary
  Position Purpose:
  Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.
  
  Education/Experience:
  Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required.
  
  Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
  Knowledge of Medicare and Medicaid regulations preferred.
  Knowledge of utilization management processes preferred.
  
  License/Certification:
  LPN - Licensed Practical Nurse - State Licensure required
  For Health Net of California: RN license required
  
  Responsibilities
  Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
  
  Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
  
  Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
  
  Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
  
  Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
  
  Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members
  
  Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
  
  Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
  
  Collaborates with care management on referral of members as appropriate
  Performs other duties as assigned
  
  Complies with all policies and standards
  
  EEO:
  
  “Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”
  
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  Job Profile Summary Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required For Health Net of California: RN license required Responsibilities Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards
  Story Behind the Need – Business Group & Key Projects
  Health plan or business unit Team culture Surrounding team & key projects Purpose of this team Reason for the request Motivators for this need Any additional upcoming hiring needs?	NC Tailored Plans- Trillium and Partners All or one and one for all- All hands on deck NA Process authorization requests for TP product Need additional team member to assist with lowering the TAT n/a No
  Typical Day in the Role
  Daily schedule & OT expectations Typical task breakdown and rhythm Interaction level with team Work environment description	Monday-Friday 8 am-5pm EST; No OT expectations Team leader creates the assignment and sends to the team daily- Team members are expected to complete nurse reviews on the assigned cases. Ones not meeting clinical criteria will need to be sent to the medical director for second lvl review Min- Except for training and day to day communication with the TP supv/Team leads Remote Approx 18 reviews per day
  Compelling Story & Candidate Value Proposition
  What makes this role interesting? Points about team culture Competitive market comparison Unique selling points Value added or experience gained	Remote; Has the ability to review IP requests One for all; All for one; All hands on deck Remote; great team Must possess at least 2 years of prior CCR Authorization experience
  Candidate Requirements
  Education/Certification	Required: Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. LPN	Preferred: RN
  Licensure	Required: NC license or Compact license	Preferred:
  Years of experience required Disqualifiers Best vs. average Performance indicators	Must haves: 2 years experience with IP auth reviews Nice to haves: Previous experience with NC State Criteria/ InterQual Criteria Disqualifiers: Performance indicators: 15 Auths reviews per day
  
  

• About the company

  Mindlance is one of the largest diversity-owned staffing firms in the US . As a recruitment centric talent acquisition company, Mindlance provides Technology, Engineering, Digital / Creative / Marketing, Clinical Research, Scientific, Finance, Professional and Payroll Management staffing services to Global 1000 companies across the US, Canada and India.

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