Clinical Care Reviewer II – Ohio RN Licensure Required

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

📋 Description

• Conduct medical necessity reviews for prospective, concurrent, and retrospective cases involving 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 concerns to the Quality Improvement department.

• Recognize and refer eligible members for Care Management services.

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

• Participate in medical advisement and State Hearing meetings upon request.

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

• Carry out other job-related responsibilities as assigned.

⛳️ Requirements

• Valid Ohio RN licensure is mandatory.

• Completion of a recognized registered nursing (RN) degree program is essential.

• An Associate of Science (A.S.) degree is required.

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

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

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

• Strong data entry skills and proficiency in navigating clinical platforms are needed.

• Familiarity with Microsoft Outlook, Word, and Excel is essential.

• Excellent oral and written communication abilities are required.

• Capability to work both independently and as part of a team is essential.

• Strong attention to detail is necessary.

• Proper grammar usage and telephone etiquette are required.

• Effective time management and prioritization skills are needed.

• A customer service orientation is essential.

• Proficient decision-making and problem-solving skills are required.

• Strong organizational abilities are needed.

• Resilience to change is essential.

• 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 insurance is preferred.

🏝️ Benefits

• Performance-based bonus linked to both company and individual achievements.

• Comprehensive total rewards package offered.

• Support for overall employee well-being provided.