Clinical Care Reviewer II (Massachusetts RN Licensure Required)

CareSource Nevada Co.; Boston (MA); On-site; USD 75,000 - 121,000; Full time

Benefits offered by this job

Health insurance

Job summary

CareSource is seeking a Clinical Care Reviewer II in Boston to review medical necessity and authorization, assist with discharge planning and care coordination for members. You will engage with care partners to facilitate transitions and monitor service delivery.

The role requires an AS in Nursing and an active RN license, with at least three years of clinical experience. Medicaid/Medicare/Commercial experience and UR/UM experience are preferred.

Qualifications

• Requires AS in Nursing and RN program completion.
• Minimum three years of clinical experience.
• Home health, med/surgical, or UM experience preferred.
• UM/Utilization Review experience preferred.
• Medicaid/Medicare/Commercial experience preferred.

Responsibilities

• Perform prospective, concurrent and retrospective reviews for clinical appropriateness of care.
• Coordinate with care partners to transition to appropriate level of care.
• Consult with medical director when clinical expertise is needed.
• Stay updated on state/federal regulations impacting CareSource.
• Identify quality issues and refer to Quality Improvement.
• Refer appropriate members for Care Management.
• Guide non-clinical staff and support LPNs as needed.
• Attend medical advisement and state hearing meetings as requested.
• Assist Team Leader with special projects.
• Perform other duties as assigned.

Skills

Data entry

Outlook

Word

Excel

Communication

Independent work

Teamwork

Attention to detail

Phone etiquette

Time management

Customer service

Education

AS in Nursing

MCG Certification within 6 months

Job description

Job Summary:

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 if 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

$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.

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.

#LI-ST1