RN Clinical Care Reviewer: Care Coordination & Utilization

Ellenco Estágios e Treinamentos; Massachusetts; Remote; USD 62,700 - 100,400; Full time

Benefits offered by this job

Bonus possible

Job summary

CareSource is seeking a Clinical Care Reviewer II to process medical necessity reviews, coordinate care and assist with discharge planning. The role supports various review types including inpatient and home health, with opportunities to collaborate with medical directors and care partners.

Required RN licensure, AS degree, and MCG certification within six months. Strong data entry, MS Office, and communication skills are essential.

Qualifications

• RN licensure current and unrestricted in practice state(s).
• AS nursing degree completed from accredited program.
• MCG certification or required within six months of hire.

Responsibilities

• Process prospective, concurrent, and retrospective reviews (inpatient, outpatient, homecare, and DME).
• Identify and coordinate care with care partners to ensure appropriate level of care.
• Engage medical director for additional clinical expertise as needed.
• Maintain knowledge of relevant regulations and accreditation standards.
• Refer quality issues to Quality Improvement.
• Refer appropriate members to Care Management.
• Provide guidance to non-clinical staff and to LPNs as appropriate.
• Attend medical advisement and state hearing meetings when requested.
• Assist Team Leader with special projects.

Skills

Data entry

Microsoft Outlook

Microsoft Word

Microsoft Excel

Communication

Time management

Attention to detail

Customer service

Decision making

Organizational skills

Change resiliency

Education

AS RN degree

MCG Certification within 6 months

Tools

Microsoft Outlook

Microsoft Word

Microsoft Excel

Job description

CareSource is seeking a Clinical Care Reviewer II to process medical necessity reviews, coordinate care and assist with discharge planning. The role supports various review types including inpatient and home health, with opportunities to collaborate with medical directors and care partners.

Required RN licensure, AS degree, and MCG certification within six months. Strong data entry, MS Office, and communication skills are essential.