RN Clinical Care Reviewer - Must have MA RN license Direct UM Experience Preferred!

CareSource; Massachusetts; Remote; USD 75.000 - 121.000; Vollzeit

Zusammenfassung

CareSource is seeking an RN Clinical Care Reviewer to process medical necessity reviews and coordinate care for members. This full-time, remote position in Massachusetts offers a competitive salary and opportunities to collaborate with an interdisciplinary team.

The role requires an RN license, 3+ years of clinical experience, and MCG Certification within six months of hire. You will stay compliant with state and federal regulations and support quality improvement initiatives.

Qualifikationen

• 3+ years of clinical experience required.
• RN licensure in state of practice required.
• MCG Certification or must be obtained within six months of hire.

Aufgaben

• Process prospective, concurrent, and retrospective reviews for medical necessity.
• Identify, document, communicate, and coordinate care with partners.
• Engage with medical director for clinical expertise as needed.
• Maintain knowledge of state and federal regulations governing CareSource.
• Identify and refer quality issues to Quality Improvement.
• Provide guidance to non-clinical staff and support to LPN staff.
• Attend medical advisement and State Hearing meetings as requested.
• Assist Team Leader with special projects or research.

Kenntnisse

Clinical experience

Ausbildung

Associate's degree or RN degree

Jobbeschreibung

About This Role

The RN Clinical Care Reviewer is responsible for processing medical necessity reviews and coordinating care for members. This role is ideal for individuals with clinical experience looking to engage in utilization management.

Highlights

• Pay: $75,200 - $120,500/year
• Location: Remote, MA
• Schedule: Full-time

What You'll Do

• Complete prospective, concurrent, and retrospective reviews for various healthcare services.
• Identify, document, communicate, and coordinate care with collaborative partners.
• Engage with the medical director for additional clinical expertise as needed.
• Maintain knowledge of state and federal regulations governing CareSource.
• Identify and refer quality issues to Quality Improvement.
• Provide guidance to non-clinical staff and support to LPN clinical staff.
• Attend medical advisement and State Hearing meetings as requested.
• Assist Team Leader with special projects or research as needed.
• Perform any other job-related duties as requested.

Requirements

Education:

• Associate's degree or completion of an accredited registered nursing (RN) degree program required

Experience:

• 3+ years clinical experience required
• Med/surgical, emergency acute clinical care, or home health experience preferred
• Utilization Management/Utilization Review experience preferred

Licenses & Certifications:

• Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required
• MCG Certification or must be obtained within six (6) months of hire required

About CareSource

CareSource is a leading healthcare provider committed to delivering exceptional patient care. They are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.