Job Summary: 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 members, as well as monitoring the delivery of healthcare services. Essential Functions: - Complete prospective, concurrent and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment - Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care - Engage with medical director when additional clinical expertise if needed - 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 - Provide guidance to non-clinical staff - Provide guidance and support to LPN clinical staff as appropriate - Attend medical advisement and State Hearing meetings, as requested - Assist Team Leader with special projects or research, as requested - Perform any other job related duties as requested. Education and Experience: - Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program required - Three (3) years clinical experience required - Med/surgical, emergency acute clinical care or home health experience preferred - Utilization Management/Utilization Review experience preferred - Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: - Proficient data entry skills and ability to navigate clinical platforms successfully - Working knowledge of Microsoft Outlook, Word, and Excel - Effective oral and written communication skills - Ability to work independently and within a team environment - Attention to detail - Proper grammar usage and phone etiquette - Time management and prioritization skills - Customer service oriented - Decision making/problem solving skills - Strong organizational skills - Change resiliency Licensure and Certification: - Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required - MCG Certification or must be obtained within six (6) months of hire required Working Conditions: - General office environment; may be required to sit or stand for extended periods of time - Travel is not typically required Compensation Range: $62,700.00 - $100,400.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-JM1

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. ***POSITION IS REMOTE BUT CANDIDATE MUST RESIDE IN THE STATE OF MISSOURI*** Position Purpose: Supports care management activities and the teams assigned to members to ensure services are delivered by the healthcare providers and partners and continuity of care/member satisfaction is achieved. Interacts with members by performing member outreach telephonically or through home-visits and documents the plan for care/services of activities. - Provides outreach to members via phone or home visits to engage members and discuss care plan/service plan including next steps, resources, questions or concerns related to recommended care, and ongoing education for the member throughout care/service, as appropriate - Coordinates care activities based on the care plan/service plan and works with healthcare and community providers and partners, and members/caregivers to accommodate changes or progress, as needed - Serves as support on various member and/or provider inquiries, requests, or concerns related to care plan/service plan - Communicates with care managers, practitioners, and others as needed to facilitate member services and to ensure continuity of care/service - May support performing service assessments/screenings for members and documenting the member’s care needs - Supports documenting and maintaining member records in accordance with state and regulatory requirements and distribution to providers as needed - Follows standards of practice and policies compliant with contractual requirements and regulatory guidelines and standards - Ability to identify needs and make referrals to Care Manager, community based organizations, and Disease Manager - Provide education on benefits and resources available - Performs other duties as assigned. - Complies with all policies and standards. Education/Experience: Requires a High School diploma or GED. Requires 1 – 2 years of related experience Pay Range: $17.84 - $28.02 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position. The UR RN specializes in examining medical records and developing concise and pertinent clinical reviews to support authorization obtainment, avoid payment denial, and optimize reimbursement. The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. The Utilization Management Case Manager is responsible for performing the initial and concurrent Utilization Reviews on all patients admitted or placed in outpatient status with observation services. MINIMUM QUALIFICATIONS: EDUCATION, CERTIFICATION, AND/OR LICENSURE: 1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC). EXPERIENCE: 1. Three (3) years of healthcare clinical experience. PREFERRED QUALIFICATIONS: EDUCATION, CERTIFICATION, AND/OR LICENSURE: 1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; Currently enrolled in a BSN program and BSN completion within three (3) years of hire. EXPERIENCE: 1. Medical Management for Medicare and/or Medicaid populations. 2. Utilization Management experience. CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned. 1. Assure effective communication of medical necessity to the applicable payor. 2. Reviews, assesses, and evaluates clinical information used to support Utilization Management (UM) decisions based on medical record documentation. 3. Facilitates professional communication to ensure the authorization process is completed in a patient centered manner with adherence to quality and timeline standards. 4. Reviews medical records and compiles concise and pertinent clinical reviews. 5. Collaborates with UR coordinators, clinical appeals, and physician advisors to prevent and manage concurrent denials. 6. Advocates for the patient and hospital with insurance companies to optimize reimbursement and hospital stay coverage 7. Collaborates with other members of the interdisciplinary team as outlined in the system UM Plan 8. Provides timely and comprehensive documentation of clinical reviews and payor communication. 9. Maintains working knowledge of payor requirements. 10. Communicates concurrent denials to appropriate team members in a timely fashion. 11. Provide highly effective reconsideration clinicals to payors in order to prevent denials 12. Liaise with hospital case management as necessary and appropriate 13. Maintains effective and efficient processes for determining appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. 14. Maintains knowledge and understanding of applicable federal regulations and Conditions of Participation. 15. Actively participates in process improvement initiatives, working with a variety of departments and multidisciplinary staff. 16. Effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment. 17. Identify delays in treatment or inappropriate utilization and serves as a resource 18. Coordinates communication with physicians and collaborates to ensure appropriate patient status. 19. This individual identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis. 20. Consistently demonstrate ability to serve as a role model and change agent by promoting the concept of teamwork and the revenue cycle process continuum of high performing teams. PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. Office work which includes sitting for extended periods of time. 2. Must have reading and comprehension ability. 3. Visual acuity must be within normal range. 4. Must be able to communicate effectively. 5. Must have manual dexterity to operate keyboard, fax machines, telephones and other business equipment. WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. Office work which includes sitting for extended periods of time. 2. Maintains confidential home office space 3. Required weekends and holidays as assigned SKILLS & ABILILTIES: 1. Effective verbal and written communication skills. 2. Strong interpersonal skills. 3. Strong attention to detail. 4. Knowledge of medical terminology required. 5. Knowledge of third party payers required. 6. Ability to use tact and diplomacy in dealing with others. 7. Working knowledge of computers. 8. Excellent customer service and telephone etiquette Additional Job Description: Scheduled Weekly Hours: 40 Shift: Exempt/Non-Exempt: United States of America (Exempt) Company: SYSTEM West Virginia University Health System Cost Center: 553 SYSTEM Utilization Review

Work Flexibility: Field-based As an Inari Field Clinical Specialist at Stryker, you will help transform the lives of patients suffering from venous and other vascular diseases together with our customers. This is a vital role in supporting our customers with advanced training, clinical expertise, and real-time procedural support to help us achieve our mission of making healthcare better. What you will do: - Provide exceptional hands-on training and education to physicians on device handling, implantation, and troubleshooting for Inari products. - Lead and facilitate in-service training sessions in clinical environments. - Partner with our Account Managers to identify opportunities and drive therapy adoption. - Be ready for on-call support for urgent clinical needs that can occur outside of standard business hours to ensure our commitment to our customers. What you need: - Associates degree in nursing or related clinical discipline preferred. - Minimum three (3) years of equivalent combination of education, training, and hands-on experience in a cath lab, nursing, or comparable clinical environment. - Proven understanding of cardiovascular science, cardiovascular anatomy, pathology and physiology - Strong clinical acumen is required. - Understanding of sales process is a plus. - Travel up to 80% of the time – both locally and regionally, and occasionally overnight. - Night/weekend on call per preplanned scheduled. - Extensive sitting, standing, and speaking. - Light lifting to 10 pounds. - Must be open to a dynamic work environment which includes regular interaction with several different physician and hospital staff customers in several locations. - Must have desire to participate in a healthcare team in the treatment of patients and anticipate needs of others. - Apply critical thinking skills to solve complex clinical problems. - Excellent command of the English language with comprehensive written and verbal communication, interpersonal, analytical, and organizational skills. - Must have the ability to concentrate on detail and work independently and meet deadlines with strong attention to detail - Comprehensive computer skills with experience in Microsoft Office with ability to develop presentation materials. Base/Draw + commission: $130K base salary and may be eligible to earn commission and/or bonuses + benefits Travel Percentage: 70% Stryker Corporation is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, ethnicity, color, religion, sex, gender identity, sexual orientation, national origin, disability, or protected veteran status. Stryker is an EO employer – M/F/Veteran/Disability. Stryker Corporation will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. Stryker is driven to work together with our customers to make healthcare better. Employees and new hires in sales and field roles that require access to customer accounts as a function of the job may be required, depending on customer requirements, to obtain the COVID-19 vaccination as an essential function of their role.