RN Care Coordination & Utilization Review Specialist

CareSource; United States; On-site; USD 63,000 - 100,000; Full time

Job summary

CareSource is seeking a Clinical Care Reviewer II to review medical necessity for authorizations, assist with discharge planning, and coordinate care for members. The role requires an RN with an AS degree, current state licensure, and 3+ years of clinical experience, preferably in Medicaid/Medicare settings.

Responsibilities include conducting prospective, concurrent, and retrospective reviews, coordinating with care partners, and guiding non-clinical staff.

Qualifications

• AS Nursing degree or RN equivalent required
• Three 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 various inpatient and home health services
• Coordinate care and transitions with care partners
• Engage medical director when clinical input is needed
• Maintain knowledge of regulations and accreditation standards
• Identify quality issues and refer to Quality Improvement
• Support Care Management referrals
• Provide guidance to staff and participate in special projects
• Attend advisement meetings as requested

Skills

Data entry

Communication skills

Independent work

Team collaboration

Attention to detail

Time management

Customer service

Decision making

Organizational skills

Change resiliency

Education

AS Nursing degree (RN)

RN licensure in state(s) of practice

MCG Certification within 6 months

Tools

MS Outlook

Microsoft Word

Microsoft Excel

Job description

CareSource is seeking a Clinical Care Reviewer II to review medical necessity for authorizations, assist with discharge planning, and coordinate care for members. The role requires an RN with an AS degree, current state licensure, and 3+ years of clinical experience, preferably in Medicaid/Medicare settings.

Responsibilities include conducting prospective, concurrent, and retrospective reviews, coordinating with care partners, and guiding non-clinical staff.