Clinical Care Reviewer II – MA RN License Required

This is a fully remote position, open to applicants in Massachusetts.

📋 Description

• Conduct thorough prospective, concurrent, and retrospective reviews, covering acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services, and durable medical equipment.

• Recognize, document, communicate, and collaborate with care partners to ensure smooth transitions to the appropriate level of care.

• Consult with the medical director when additional clinical expertise is necessary.

• Stay informed about state and federal regulations, CareSource requirements, State Contracts, Provider Agreements, benefits, and accreditation standards.

• Identify and refer quality concerns to the Quality Improvement team.

• Identify and refer suitable members for Care Management services.

• Offer guidance to non-clinical staff.

• Provide guidance and support to LPN clinical staff as needed.

• Participate in medical advisement and State Hearing meetings when requested.

• Assist the Team Leader with special projects or research as needed.

• Perform additional job-related duties as assigned.

⛳️ Requirements

• Completion of an accredited Associate of Science (A.S) degree in registered nursing (RN) is required.

• Current, unrestricted Registered Nurse (RN) Licensure in the state(s) of practice is required.

• MCG Certification is required or must be obtained within six (6) months of hire.

• A minimum of three (3) years of clinical experience is required.

• Experience in med/surgical, emergency acute clinical care, or home health is preferred.

• Experience in Utilization Management/Utilization Review is preferred.

• Medicaid/Medicare/Commercial experience is preferred.

• Proficient in data entry and skilled in navigating clinical platforms effectively.

• Working knowledge of Microsoft Outlook, Word, and Excel is necessary.

• Strong oral and written communication skills are essential.

• Ability to work both independently and collaboratively within a team environment.

• Strong attention to detail is required.

• Proper grammar usage and phone etiquette are important.

• Excellent time management and prioritization skills are needed.

• Customer service orientation is a must.

• Good decision-making and problem-solving skills are essential.

• Strong organizational skills are required.

• Ability to adapt to change is necessary.

🏝️ Benefits

• Bonus linked to both company and individual performance.

• Comprehensive and substantial total rewards package.

• Typically, travel is not required.