Remote RN - Clinical Care & Utilization Review

CareSource; Massachusetts; Remote; USD 75,000 - 121,000; Full time

Job summary

CareSource is seeking an RN Clinical Care Reviewer to process medical necessity reviews and coordinate care for members. This full-time, remote position in Massachusetts offers a competitive salary and opportunities to collaborate with an interdisciplinary team.

The role requires an RN license, 3+ years of clinical experience, and MCG Certification within six months of hire. You will stay compliant with state and federal regulations and support quality improvement initiatives.

Qualifications

• 3+ years of clinical experience required.
• RN licensure in state of practice required.
• MCG Certification or must be obtained within six months of hire.

Responsibilities

• Process prospective, concurrent, and retrospective reviews for medical necessity.
• Identify, document, communicate, and coordinate care with partners.
• Engage with medical director for clinical expertise as needed.
• Maintain knowledge of state and federal regulations governing CareSource.
• Identify and refer quality issues to Quality Improvement.
• Provide guidance to non-clinical staff and support to LPN staff.
• Attend medical advisement and State Hearing meetings as requested.
• Assist Team Leader with special projects or research.

Skills

Clinical experience

Education

Associate's degree or RN degree

Job description

CareSource is seeking an RN Clinical Care Reviewer to process medical necessity reviews and coordinate care for members. This full-time, remote position in Massachusetts offers a competitive salary and opportunities to collaborate with an interdisciplinary team.

The role requires an RN license, 3+ years of clinical experience, and MCG Certification within six months of hire. You will stay compliant with state and federal regulations and support quality improvement initiatives.