RN Clinical Care Reviewer II - Care Coordination

CareSource Management Services LLC; Ohio; Hybrid; USD 63,000 - 100,000; Full time

Job summary

CareSource in Ohio seeks a Clinical Care Reviewer II to process medical necessity reviews for authorization of health care services, assist with discharge planning (DME, home health) and coordinate care for members, while monitoring service delivery.

Responsibilities include reviewing prospective, concurrent and retrospective cases, coordinating with care partners, consulting with medical directors, and staying current with regulations. RN licensure and 3+ years clinical experience required.

Qualifications

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

Responsibilities

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

Skills

Proficient data entry

Microsoft Outlook

Microsoft Word

Microsoft Excel

Effective communication

Teamwork

Attention to detail

Time management

Customer service oriented

Decision making

Organizational skills

Change resiliency

Education

Associates of Science (A.S)

Registered Nurse (RN) Licensure

MCG Certification

Tools

Microsoft Outlook

Microsoft Word

Microsoft Excel

Job description

CareSource in Ohio seeks a Clinical Care Reviewer II to process medical necessity reviews for authorization of health care services, assist with discharge planning (DME, home health) and coordinate care for members, while monitoring service delivery.

Responsibilities include reviewing prospective, concurrent and retrospective cases, coordinating with care partners, consulting with medical directors, and staying current with regulations. RN licensure and 3+ years clinical experience required.