RN Care Navigator & Utilization Reviewer

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

Job summary

CareSource is seeking a Clinical Care Reviewer II to process medical necessity reviews and support discharge planning and care coordination for members. The role involves reviewing admissions, home health services and DME, and collaborating with care partners to ensure appropriate levels of care.

The position requires RN licensure, at least 3 years of clinical experience, and familiarity with utilization management. Strong communication and organizational skills are essential.

Qualifications

• RN licensure in state(s) of practice required
• 3 years clinical experience required
• Utilization Management/Utilization Review experience preferred
• Medicaid/Medicare/Commercial experience preferred
• MCG Certification or must be obtained within six months of hire required

Responsibilities

• Process prospective, concurrent and retrospective reviews for medical necessity
• Coordinate care transitions and engage care partners
• Consult with medical director as needed
• Maintain knowledge of regulations and provider agreements
• Identify quality issues and refer to Quality Improvement
• Identify members for Care Management
• Guide non-clinical staff and LPN staff
• Attend advisement and state hearing meetings
• Support Team Leader with special projects
• Perform other duties as requested

Skills

Data entry

MS Outlook

MS Word

MS Excel

Oral and written communication

Independence and teamwork

Attention to detail

Time management

Customer service

Decision making

Education

AS RN degree

Tools

MS Outlook

MS Word

MS Excel

Job description

CareSource is seeking a Clinical Care Reviewer II to process medical necessity reviews and support discharge planning and care coordination for members. The role involves reviewing admissions, home health services and DME, and collaborating with care partners to ensure appropriate levels of care.

The position requires RN licensure, at least 3 years of clinical experience, and familiarity with utilization management. Strong communication and organizational skills are essential.