RN Care Coordination & Utilization Reviewer II

CareSource Nevada Co.; Boston (MA); On-site; USD 75,000 - 121,000; Full time

Benefits offered by this job

Health insurance

Job summary

CareSource is seeking a Clinical Care Reviewer II in Boston to review medical necessity and authorization, assist with discharge planning and care coordination for members. You will engage with care partners to facilitate transitions and monitor service delivery.

The role requires an AS in Nursing and an active RN license, with at least three years of clinical experience. Medicaid/Medicare/Commercial experience and UR/UM experience are preferred.

Qualifications

• Requires AS in Nursing and RN program completion.
• Minimum three years of clinical experience.
• Home health, med/surgical, or UM experience preferred.
• UM/Utilization Review experience preferred.
• Medicaid/Medicare/Commercial experience preferred.

Responsibilities

• Perform prospective, concurrent and retrospective reviews for clinical appropriateness of care.
• Coordinate with care partners to transition to appropriate level of care.
• Consult with medical director when clinical expertise is needed.
• Stay updated on state/federal regulations impacting CareSource.
• Identify quality issues and refer to Quality Improvement.
• Refer appropriate members for Care Management.
• Guide non-clinical staff and support LPNs as needed.
• Attend medical advisement and state hearing meetings as requested.
• Assist Team Leader with special projects.
• Perform other duties as assigned.

Skills

Data entry

Outlook

Word

Excel

Communication

Independent work

Teamwork

Attention to detail

Phone etiquette

Time management

Customer service

Education

AS in Nursing

MCG Certification within 6 months

Job description

CareSource is seeking a Clinical Care Reviewer II in Boston to review medical necessity and authorization, assist with discharge planning and care coordination for members. You will engage with care partners to facilitate transitions and monitor service delivery.

The role requires an AS in Nursing and an active RN license, with at least three years of clinical experience. Medicaid/Medicare/Commercial experience and UR/UM experience are preferred.