Complex Population, Service Determination Specialist II

Job Summary:

Complex Population Service Determination Specialist II is responsible for processing medical necessity and noncommunity supports and service health care reviews for appropriateness of authorization to include home and community-based supports. This role assists with discharge planning activities and care coordination for members enrolled with a CareSource Management Group line of business, as well as monitoring the delivery of healthcare services in a cost-effective manner.  

Essential Functions:

• Compares PCSP to service request submitted by provider to ensure accuracy and need for services
• Conducts front and back end reviews of services approved in Cite Auto Auth or by staff
• Works with provider network and Care Coordination to communicate and address provider concerns resulting from clinical quality audits and/or cite auto auth reviews 
• Leads collaboration with Care Coordination on transition and discharge plans for members receiving highest levels of I/DD and BH treatment
• Responsible for the prior authorization of BH/SUD/IDD/HCBS/Waiver PASSE services.
• Responsible for retro-authorization requests and continued stay reviews
• Collaboration with Medical Directors and Care Coordinators to ensure the best service is in place
• Familiar with Evidence Based Care systems such as MCG, ASAM, HCBS waiver guidelines
• Maintain knowledge of state and federal regulations governing CareSource, state contracts, provider agreements, benefits, and NCQA standards
• Consistent application of criteria and processes
• Successful Inter-rater reliability scores evidenced by routine audits
• Identify and refer compliance quality issues to Quality Improvement and Network Management
• Identify and present (verbal or written) clinical cases to the appropriate Medical Directors for appropriate determination of the requested service
• Conducts research to ensure census reports are accurate and up to date
• Perform any other job-related instructions, as requested including adding services and processes related to the development of new lines of business
• Perform any other job duties as requested

Education and Experience:

• Nursing degree from an accredited registered nursing (RN) program or Bachelor’s degree in a health care field or equivalent years of relevant work experience is required
• Prior experience in utilization review and/or case management working with BH/SUD/IDD/HCBS/Waiver is preferred
• Experience with Medicaid, Medicare, Commercial and Managed Care is preferred

Competencies, Knowledge and Skills:

• Basic data entry skills
• Knowledge of Microsoft Word, Excel and Access
• Communication Skills; written and verbal
• Ability to work independently and within a team environment
• Familiarity of the healthcare field
• Proper usage of grammar
• Decision making/problem solving skills
• Proper phone etiquette
• Customer service oriented

Licensure and Certification:

• Current unrestricted clinical license in state of practice as a Registered Nurse, Social Worker, Psychologist or Clinical Counselor is required
• Valid licensure or certification in Substance Use preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource 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):

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.