Registered Nurse - Clinical Care & Utilization Reviewer II

CareSource; United States; Remote; USD 75,000 - 121,000; Full time

Benefits offered by this job

Competitive salary

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 supports transitions to appropriate levels of care and engages with clinical partners as needed.

Requirements include an AS in Nursing and RN licensure, with a minimum of 3 years clinical experience. Proficiency with MS Office and strong communication skills are essential.

Qualifications

• AS in Nursing required.
• RN licensure in state(s) of practice required.
• Minimum 3 years of clinical experience.

Responsibilities

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

Skills

Data entry

Communication skills

Time management

Team collaboration

Attention to detail

Customer service

Education

AS in Nursing

RN licensure

Tools

Microsoft Outlook

Microsoft Word

Microsoft Excel

Job description

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 supports transitions to appropriate levels of care and engages with clinical partners as needed.

Requirements include an AS in Nursing and RN licensure, with a minimum of 3 years clinical experience. Proficiency with MS Office and strong communication skills are essential.