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Service Determination Specialist II
CareSource. Process medical necessity and noncommunity supports and service healthcare reviews for authorization appropriateness, including home and community-based supports .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in healthcare authorization processes, including prior authorization for BH/SUD/IDD/HCBS/Waiver services, while ensuring compliance with state and federal regulations. Proficient in care coordination and discharge planning, with strong communication and decision-making skills.
Highest-signal resume keywords
Registered Nurse LicenseUtilization Review ExperienceCase Management ExperienceKnowledge of Medicaid and MedicareEvidence Based Care Systems
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Prior AuthorizationUtilization ReviewCare CoordinationData EntryClinical Case PresentationService Request ComparisonHealthcare ReviewInter-Rater Reliability MaintenanceCompliance Quality IdentificationCensus Report Research
Soft Skills
Written CommunicationVerbal CommunicationDecision-MakingProblem-SolvingCustomer Service Orientation
Tools & Technologies
Microsoft WordMicrosoft ExcelMicrosoft Access
Certifications & Qualifications
Clinical LicenseSubstance Use Certification
Industry Keywords
BH/SUD/IDD/HCBS/WaiverCareSource Management GroupNCQA StandardsClinical Quality AuditsHome and Community-Based Supports
About the role
Key responsibilities & impact- Process medical necessity and noncommunity supports and service healthcare reviews for authorization appropriateness, including home and community-based supports
- Assist with discharge planning and care coordination for members enrolled with a CareSource Management Group line of business
- Monitor delivery of healthcare services in a cost-effective manner
- Compare PCSP to provider-submitted service requests to ensure accuracy and need
- Conduct front-end and back-end reviews of services approved in Cite Auto Auth or by staff
- Work with provider network and Care Coordination to address concerns from clinical quality audits and Cite Auto Auth reviews
- Lead collaboration with Care Coordination on transition and discharge plans for members receiving the highest levels of I/DD and BH treatment
- Perform prior authorization of BH/SUD/IDD/HCBS/Waiver PASSE services
- Process retro-authorization requests and continued stay reviews
- Collaborate with Medical Directors and Care Coordinators to ensure the best service is in place
- Apply Evidence Based Care systems and applicable guidelines, including MCG, ASAM, and HCBS waiver guidelines
- Maintain knowledge of state and federal regulations, state contracts, provider agreements, benefits, and NCQA standards
- Apply criteria and processes consistently
- Maintain successful inter-rater reliability scores through routine audits
- Identify and refer compliance quality issues to Quality Improvement and Network Management
- Identify and present clinical cases to appropriate Medical Directors for service determinations
- Research to ensure census reports are accurate and up to date
- Add services and processes related to new lines of business as requested
- Perform other job-related duties as requested
Requirements
What you’ll need- Nursing degree from an accredited registered nursing (RN) program, Bachelor’s degree in a health care field, or equivalent years of relevant work experience is required
- Current unrestricted clinical license in state of practice as a Registered Nurse, Social Worker, Psychologist, or Clinical Counselor 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
- Valid licensure or certification in Substance Use is preferred
- Basic data entry skills
- Knowledge of Microsoft Word, Excel, and Access
- Written and verbal communication skills
- Ability to work independently and within a team environment
- Familiarity with the healthcare field
- Proper usage of grammar
- Decision-making and problem-solving skills
- Proper phone etiquette
- Customer service orientation
Benefits
Comp & perks- Bonus tied to company and individual performance may be available
- Substantial and comprehensive total rewards package
- Equal Opportunity Employer fostering an environment of belonging