If you’re an experienced RN Clinical Assessor seeking an exciting new opportunity, look no further! We’re in search of someone who thrives in a collaborative and welcoming environment to join our team. If you’re ready for a new challenge and want to contribute to a positive workplace culture, you encouraged to apply!
Summary of Qualifications:
We are currently seeking a registered nurse (RN) clinical assessor for an exciting opportunity. In this role, you’ll have the flexibility of working from your home office while traveling to assessment locations within your region (New Kent & Williamsburg). As a RN Clinical Assessor, you’ll play a dual role: first, as a care coordinator conducting needs-based assessments to determine the appropriate level of care for individuals, facilitating their ability to remain in or transition back to a home and community-based setting. These assessments are typically conducted in the beneficiary’s primary residence. Secondly, you’ll serve as a pre-authorization nurse, reviewing requests for medical treatments, services, or procedures for Medicaid fee-for-service services. This aspect of the role involves assessing, evaluating, and providing recommendations to ensure that members receive the necessary services they require. It’s an opportunity to make a meaningful impact on individuals’ lives while contributing to the healthcare system’s efficiency and effectiveness.
Accountabilities:
- Conducts assessment to determine whether the beneficiary meets the conditions and criteria for CMS wavier eligibility, using state-approved standardized assessment tool(s).
- Establish a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality outcomes.
- Interact and collaborate with multidisciplinary care team, which includes physicians, nurses, case managers, pharmacists, and social workers/educators to ensure beneficiary needs and preferences for health services/information is shared; educates beneficiaries about community resources/options; advocates on behalf of the beneficiary.
- Prepare documentation, status updates, event notifications and other documentation regarding beneficiaries in accordance with regulatory requirements and company policies and procedures.
- Monitor case load to ensure all required documentation and entry of assessment results into web-based database are completed accurately and timely.
- Attend and actively participate in staff meetings and conduct case consultations/peer reviews/internal auditing as assigned.
- Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care; determines if the medical record documentation supports the need for services.
- Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail on correspondence.
The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.
Knowledge, Skills, and Abilities:
- Knowledge of standards of practice related to Medicaid waivers, home, and community-based services (HCBS) programs, EPSDT, medical fragility, and level of care determinations.
- Develops level of care recommendations based upon clinical evaluations.
- Ability to use person-centered thinking, planning, and have competency in awareness of the needs of persons with disabilities.
- Ability to interact with healthcare professionals, patients, their families, and other supports.
- Knowledge of InterQual criteria strongly preferred.
- Knowledge of current NCQA/URAC standards strongly preferred
- Medical record abstracting skills required.
- Knowledge of the organization of medical records, medical terminology, and disease process required.
- Strong clinical assessment and critical thinking skills required.
- Excellent verbal and written communication skills required.
- Ability to work in a team environment.
- Flexibility and strong organizational skills needed.
- Computer proficiency in Microsoft Excel, Word and Outlook.
- Ability to utilize computer equipment and web-based software to conduct work.
Experience:
- Experience with community-based individuals needing personal assistance with ADL and IADL tasks is highly preferred.
- 1+ years of experience (preferably case management) in the health or medical field, directly related to homecare, long-term care, or personal care is required.
- Minimum of one year UR and/or Prior Authorization or related experience.
Required Qualifications:
- Registered Nurse licensed by the state of Virginia
- Minimum of two years’ experience in home care setting preferred.
Attention Applicants: Please be advised that proper email communication will only be sent from email addresses ending in @astyra.com. Please ensure you are communicating with approved Astyra recruiters by checking this point when receiving offers and messages from us. It is important to communicate within our guidelines and proper channels to expedite possible interview considerations.
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