Complex Population, Service Determination Specialist II

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.
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
Responsible for the prior authorization of BH/SUD/IDD/HCBS/Waiver PASSE services.
Collaboration with Medical Directors and Care Coordinators to ensure the best service is in place
Consistent application of criteria and processes
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
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
Experience with Medicaid, Medicare, Commercial and Managed Care is preferred
Basic data entry skills
Knowledge of Microsoft Word, Excel and Access
Familiarity of the healthcare field
Proper phone etiquette
Customer service oriented
General office environment; 56,430.00 - $90,360.00 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. Compensation Type (hourly/salary):
Hourly Organization Level Competencies
Cultivate Partnerships
Pursue Personal Excellence
We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
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