Clinical Care Reviewer II (Remote)(Must Have - Unrestricted Massachusetts RN License)
$62,700–$100,400 year
RemoteMassachusetts, United States
Job Summary
Process prospective, concurrent, and retrospective reviews for acute inpatient, post-acute, elective inpatient, outpatient procedures, homecare services, and durable medical equipment. Identify, document, and coordinate care by engaging collaborative partners to facilitate transitions to appropriate levels of care. Monitor healthcare service delivery, communicate with medical directors for additional clinical expertise, and refer quality issues to Quality Improvement. Assist team leaders with special projects, research, and medical advisement meetings, while providing guidance to non-clinical and LPN staff. Maintain knowledge of state and federal regulations governing CareSource contracts, benefits, and accreditation standards.
Required Qualifications
- Associates of Science (A.S)
- Completion of an accredited registered nursing (RN) degree program
- Three (3) years clinical experience
- Med/surgical, emergency acute clinical care or home health experience
- Utilization Management/Utilization Review experience
- Medicaid/Medicare/Commercial experience
- Proficient data entry skills
- Ability to navigate clinical platforms successfully
- Working knowledge of Microsoft Outlook, Word, and Excel
- Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice
- MCG Certification or must be obtained within six (6) months of hire
- Unrestricted Massachusetts RN License
Desired Qualifications
- Med/surgical, emergency acute clinical care or home health experience
- Utilization Management/Utilization Review experience
- Medicaid/Medicare/Commercial experience
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