RN Clinical Care Reviewer II — Care Coordination

CareSource Management Services LLC; Massachusetts; Hybrid; USD 75,000 - 121,000; Full time

Job summary

CareSource in United States is seeking an experienced Registered Nurse for a Clinical Care Reviewer II role to process medical necessity reviews and assist with discharge planning and care coordination for members. The role involves supporting DME, home health services, and ensuring appropriate levels of care.

The ideal candidate holds an RN license with an Associate degree or higher, at least three years of clinical experience, and familiarity with Utilization Management and Medicaid/Medicare.

Qualifications

• Completion of an accredited registered nursing (RN) degree program.
• Three years of clinical experience required.
• Med/surgical, emergency acute or home health experience preferred.
• Utilization Management/Utilization Review experience preferred.
• Medicaid/Medicare/Commercial experience preferred.

Responsibilities

• Complete prospective, concurrent and retrospective reviews for admissions and services.
• Coordinate care with partners to facilitate transitions to appropriate care.
• Engage with medical director when additional clinical expertise is needed.
• Maintain knowledge of regulations, contracts and accreditation standards.
• Identify quality issues and refer to Quality Improvement.
• Refer appropriate members for Care Management.
• Provide guidance to non-clinical staff.
• Support LPN staff as appropriate.
• Attend medical advisement and State Hearing meetings as requested.
• Assist Team Leader with special projects or research.
• Perform other related duties as requested.

Skills

Data entry

Communication skills

Teamwork

Attention to detail

Time management

Customer service

Decision making

Organizational skills

Change resiliency

Education

AS in Nursing (A.S)

Tools

Microsoft Outlook

Microsoft Word

Microsoft Excel

Job description

CareSource in United States is seeking an experienced Registered Nurse for a Clinical Care Reviewer II role to process medical necessity reviews and assist with discharge planning and care coordination for members. The role involves supporting DME, home health services, and ensuring appropriate levels of care.

The ideal candidate holds an RN license with an Associate degree or higher, at least three years of clinical experience, and familiarity with Utilization Management and Medicaid/Medicare.