Clinical Care Reviewer II – RN, Compact License

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $62.7k - $100.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Conduct prospective, concurrent, and retrospective medical necessity reviews of post-acute admissions and related services • Complete clinical reviews for new and continued stays in post-acute services • Facilitate timely and cost-effective member discharges to the appropriate level of care • Refer cases to CareSource Medical Directors when clinical criteria are not met or a case conference is needed • Maintain knowledge of state and federal regulations, state contracts, provider agreements, policies, benefits, and accreditation standards • Identify and refer quality issues to the Quality Improvement department • Refer members receiving post-acute services to Care Management and escalate changing member needs • Document discharge planning needs and communicate with providers, care managers, discharge planners, Provider Relations, and external stakeholders • Participate in inter-rater reliability audits • Attend department huddles, team meetings, and staff meetings • Provide guidance and support to non-clinical utilization management staff • Attend medical advisement and State Hearing meetings as requested • Assist the Team Leader with special projects or research tasks • Perform other related duties as requested

🎯 Requirements

• Completion of an accredited registered nursing (RN) degree program required • Three (3) years of clinical experience required • Med/surgical, emergency, acute clinical care or Post Acute Care experience preferred • Utilization Management/Utilization Review experience preferred • Medicaid/Medicare/Commercial experience preferred • Basic data entry skills and internet utilization skills • 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 • Familiarity of the healthcare field • 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 is required or must be obtained within six (6) months of hire • Availability to work scheduled weekend and holiday hours, including all 365 days

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Employee total well-being support

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