Clinical Care Reviewer II – Unrestricted Massachusetts RN License

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

📋 Description

• Conduct reviews of medical necessity for prospective, concurrent, and retrospective health care services.

• Evaluate acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, home care services, and durable medical equipment.

• Identify, document, communicate, and collaborate with care partners to coordinate patient care.

• Facilitate seamless transitions to appropriate levels of care.

• Consult with the medical director when additional clinical insights are required.

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

• Recognize and refer quality issues to the Quality Improvement team.

• Identify and refer eligible members for Care Management services.

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

• Participate in medical advisement and State Hearing meetings as needed.

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

• Carry out other job-related duties as assigned.

⛳️ Requirements

• Associate of Science (A.S.) degree.

• Completion of an accredited registered nursing (RN) degree program is mandatory.

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

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

• Previous experience in Utilization Management/Utilization Review is preferred.

• Familiarity with Medicaid, Medicare, or Commercial insurance is preferred.

• Proficient data entry skills and a strong ability to navigate clinical platforms effectively.

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

• Excellent oral and written communication skills.

• Ability to work both independently and collaboratively in a team setting.

• Strong attention to detail.

• Proper grammar usage and phone etiquette are essential.

• Effective time management and prioritization skills.

• Customer service oriented.

• Strong decision-making and problem-solving abilities.

• Exceptional organizational skills.

• Resilience in the face of change.

• 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.

🏝️ Benefits

• Opportunity for bonuses based on company and individual performance.

• Comprehensive total rewards package.

• Support for overall employee well-being.