*This person must be licensed in Ohio, or have a multi state RN license. *

Location: 100% remote

Shift: 1st shift, M-F

Term of Assignment: ASAP – 9/30/2024

Description: The Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for enrolled members, as well as monitoring the delivery of healthcare services in a cost effective manner.

Essential Functions:

• 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 Medical Directors when clinical criterial is not met or case conference is needed/appropriate

• Maintain knowledge of state and federal regulations, 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 and LISW 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

Qualifications: The idea candidate will have 1+ years of experience with remote managed care servicing Medicare and Medicaid. Med/surgical, emergency acute clinical care, or home health experience is also preferred. Must have an Ohio or multi-state nursing license.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

Diversity, Equity & Inclusion

At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:

• Hiring diverse talent

• Maintaining an inclusive environment through persistent self-reflection

• Building a culture of care, engagement, and recognition with clear outcomes

• Ensuring growth opportunities for our people

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.