RN Care Coordination & Utilization Review Specialist

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

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.