RN Clinical Care Reviewer II – Care Coordination & UM

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

Benefits offered by this job

Bonus program

Total rewards package

Job summary

CareSource is seeking a Clinical Care Reviewer II for Massachusetts to process medical necessity reviews for authorization of health care services. The role supports discharge planning, DME, home health services, and care coordination for members, while monitoring care delivery.

The position involves prospective, concurrent and retrospective reviews, collaboration with care partners, and ongoing regulatory knowledge.

Qualifications

• Associates degree or completion of an accredited registered nursing (RN) degree program required.
• Three (3) years clinical experience required.
• Med/surgical, emergency acute clinical care 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 procedures.
• Identify, document, and coordinate care across care partners to facilitate appropriate transitions.
• Engage with medical director for clinical expertise as needed.
• Maintain knowledge of regulations governing CareSource and contracts.
• Refer quality issues to Quality Improvement and appropriate members to Care Management.
• Guide non-clinical staff and support LPN staff as appropriate.
• Attend medical advisement and State Hearing meetings when requested.
• Assist Team Leader with special projects or research.

Skills

Data entry

MS Outlook/Word/Excel

Communication skills

Independence and teamwork

Attention to detail

Grammar & phone etiquette

Time management

Customer service

Decision making

Organizational skills

Education

Associate degree or RN program completed

Job description

CareSource is seeking a Clinical Care Reviewer II for Massachusetts to process medical necessity reviews for authorization of health care services. The role supports discharge planning, DME, home health services, and care coordination for members, while monitoring care delivery.

The position involves prospective, concurrent and retrospective reviews, collaboration with care partners, and ongoing regulatory knowledge.