Clinical Care Reviewer II – RN

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🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $62.7k - $100.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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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

• Complete prospective, concurrent, and retrospective medical necessity reviews for 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 to 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 state contracts and 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 • Provide guidance and support to LPN clinical staff as appropriate • 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

• Completion of an accredited registered nursing (RN) degree program required • Three (3) years of 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 • 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 • 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 orientation • Decision-making/problem-solving skills • Strong organizational skills • Change resiliency

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Substantial and comprehensive total rewards package • Employee total well-being support • Equal Opportunity Employer environment focused on belonging and support