Clinical Care Reviewer II – Massachusetts RN Licensure Required

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

📋 Description

• Conduct reviews for medical necessity, encompassing prospective, concurrent, and retrospective evaluations for healthcare services.

• Support discharge planning processes, including durable medical equipment (DME) and home health services.

• Coordinate member care and oversee the implementation of healthcare services.

• Carry out assessments for 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 suitable levels of care.

• Collaborate with the medical director when additional clinical expertise is required.

• Stay informed about state and federal regulations, CareSource contracts, provider agreements, benefits, and accreditation standards.

• Identify and escalate quality issues to the Quality Improvement team.

• Identify and refer suitable members for Care Management services.

• Provide support and guidance to non-clinical staff and LPN clinical staff as necessary.

• Attend medical advisement and State Hearing meetings as required.

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

• Execute other job-related responsibilities as assigned.

⛳️ Requirements

• A degree from an accredited registered nursing (RN) program is mandatory.

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

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

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

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

• Experience in Utilization Management/Utilization Review is preferred.

• Familiarity with Medicaid/Medicare/Commercial practices is preferred.

• Proficient data entry skills and the ability to navigate clinical platforms effectively are necessary.

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

• Strong oral and written communication skills are essential.

• Ability to work independently as well as collaboratively in a team setting.

• Attention to detail is crucial.

• Proficient grammar usage and phone etiquette are necessary.

• Effective time management and prioritization skills are expected.

• A customer service-oriented mindset is essential.

• Strong decision-making and problem-solving abilities are required.

• Excellent organizational skills are necessary.

• Resilience to change is valued.

🏝️ Benefits

• Potential bonus linked to both company and individual performance may be available.

• A substantial and comprehensive total rewards package is offered.

• Total well-being support is provided.