Clinical Care Reviewer II - MA RN License required - Direct UM experience strongly preferred!

CareSource Management Services; Massachusetts; Hybrid; USD 75,000 - 121,000; Full time

Job summary

CareSource is seeking a Clinical Care Reviewer II to process medical necessity reviews and assist with discharge planning and care coordination for members. The role involves inpatient, home health, DME reviews, policy adherence, and collaboration with care partners.

Education includes an AS RN with active RN licensure; 3 years clinical experience and preferred UM/UR or Medicaid/Medicare exposure. Travel not typically required; hourly compensation and total rewards package are offered.

Qualifications

• 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.

Responsibilities

• Process prospective, concurrent and retrospective reviews for medical necessity.
• Coordinate care and transitions to appropriate level of care.
• Engage with medical director for clinical expertise.
• Maintain knowledge of regulations governing CareSource and contracts.
• Identify and refer quality issues to Quality Improvement.
• Identify and refer members for Care Management.
• Provide guidance to non-clinical staff.
• Support LPN staff as appropriate.
• Attend medical advisement and State Hearing meetings.
• Assist Team Leader with special projects or research.
• Perform other duties as requested.

Skills

Communication

Time management

Customer service

Teamwork

Attention to detail

Problem solving

Decision making

Organizational skills

Change resiliency

Self-management

Education

RN degree program

RN licensure

MCG Certification

Tools

Microsoft Outlook

Microsoft Word

Microsoft Excel

Job description

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 is 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:

$75,200.00 - $120,500.00 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. 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.

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Brand=Commonwealth Care Alliance