Clinical Care Reviewer II – Unrestricted Massachusetts RN License
Posted 11ds ago
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Job Description
Clinical care reviewer processing medical necessity reviews and coordinating care for CareSource health plan members. Supporting authorization, discharge planning, quality improvement, and care management referrals.
Responsibilities:
- Process prospective, concurrent, and retrospective medical necessity reviews for health care services
- Review acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services, and durable medical equipment
- Identify, document, communicate, and coordinate care with collaborative care partners
- Facilitate transitions to an appropriate level of care
- Engage with the medical director when additional clinical expertise is needed
- Maintain knowledge of state and federal regulations, CareSource contracts, provider agreements, benefits, and accreditation standards
- Identify and refer quality issues to Quality Improvement
- Identify and refer appropriate members for Care Management
- Provide guidance to non-clinical staff and support LPN clinical staff
- Attend medical advisement and State Hearing meetings as requested
- Assist the Team Leader with special projects or research as requested
- Perform other job-related duties as requested
Requirements:
- Associates of Science (A.S.)
- 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
- Proficient data entry skills and ability to navigate clinical platforms successfully
- Working knowledge of Microsoft Outlook, Word, and Excel
- Effective oral and written communication skills
- Ability to work independently and within a team environment
- Attention to detail
- Proper grammar usage and phone etiquette
- Time management and prioritization skills
- Customer service oriented
- Decision making/problem solving skills
- Strong organizational skills
- Change resiliency
- Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required
- MCG Certification required or must be obtained within six (6) months of hire
Benefits:
- Potential bonus tied to company and individual performance
- Comprehensive total rewards package
- Employee total well-being support
