Clinical Care Reviewer II (Massachusetts RN Licensure Required)

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

Job summary

CareSource in United States is seeking an experienced Registered Nurse for a Clinical Care Reviewer II role to process medical necessity reviews and assist with discharge planning and care coordination for members. The role involves supporting DME, home health services, and ensuring appropriate levels of care.

The ideal candidate holds an RN license with an Associate degree or higher, at least three years of clinical experience, and familiarity with Utilization Management and Medicaid/Medicare.

Qualifications

• Completion of an accredited registered nursing (RN) degree program.
• Three years of clinical experience required.
• Med/surgical, emergency acute or home health experience preferred.
• Utilization Management/Utilization Review experience preferred.
• Medicaid/Medicare/Commercial experience preferred.

Responsibilities

• Complete prospective, concurrent and retrospective reviews for admissions and services.
• Coordinate care with partners to facilitate transitions to appropriate care.
• Engage with medical director when additional clinical expertise is needed.
• Maintain knowledge of regulations, contracts and accreditation standards.
• Identify quality issues and refer to Quality Improvement.
• Refer appropriate members for Care Management.
• Provide guidance to non-clinical staff.
• Support LPN staff as appropriate.
• Attend medical advisement and State Hearing meetings as requested.
• Assist Team Leader with special projects or research.
• Perform other related duties as requested.

Skills

Data entry

Communication skills

Teamwork

Attention to detail

Time management

Customer service

Decision making

Organizational skills

Change resiliency

Education

AS in Nursing (A.S)

Tools

Microsoft Outlook

Microsoft Word

Microsoft Excel

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

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.

#LI-ST1 Brand=CareSource

The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference-makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer-centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we're looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.