RN Clinical Care Reviewer II - Care Coordination & UR

CareSource Nevada Co.; Columbus (OH); On-site; USD 63,000 - 100,000; Full time

Benefits offered by this job

Bonus opportunity

Total rewards package

Job summary

CareSource is seeking a Clinical Care Reviewer II in Columbus, OH to process medical necessity reviews for authorization of health care services, assist with discharge planning, and coordinate care for members. Responsibilities include conducting prospective, concurrent, and retrospective reviews, engaging care partners to facilitate transitions, and supporting LPN staff and non-clinical teams.

A RN license and 3 years of clinical experience are required, with Medicaid/Medicare experience

Qualifications

• RN licensure in state(s) of practice required.
• Three years of clinical experience required.
• Prior utilization management or Medicaid/Medicare experience preferred.
• Experience with home health, DME, or care coordination is a plus.

Responsibilities

• Perform prospective, concurrent, and retrospective reviews for medical necessity.
• Coordinate care and transitions to appropriate levels of care.
• Engage with medical director for complex cases as needed.
• Maintain knowledge of regulations and provider agreements.
• Refer quality issues to Quality Improvement and Care Management.
• Provide guidance to non-clinical staff and LPNs.
• Attend advisement and state hearing meetings when requested.
• Assist Team Leader with special projects.

Skills

RN licensure

Clinical review

Data entry

MS Office

Communication skills

Time management

Attention to detail

Team collaboration

Education

AS in Nursing (RN program)

Job description

CareSource is seeking a Clinical Care Reviewer II in Columbus, OH to process medical necessity reviews for authorization of health care services, assist with discharge planning, and coordinate care for members. Responsibilities include conducting prospective, concurrent, and retrospective reviews, engaging care partners to facilitate transitions, and supporting LPN staff and non-clinical teams.

A RN license and 3 years of clinical experience are required, with Medicaid/Medicare experience