RN Clinical Care Reviewer – MA RN License Required, Direct UM Experience Preferred

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

📋 Description

• Conduct reviews for medical necessity, including prospective, concurrent, and retrospective assessments for healthcare services.

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

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

• Execute reviews for various admissions, including acute inpatient, post-acute, elective inpatient, outpatient procedures, homecare services, and durable medical equipment.

• Identify, 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 requirements, State Contracts, Provider Agreements, benefits, and accreditation standards.

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

• Identify and refer members who may benefit from Care Management services.

• Provide direction to non-clinical staff and support LPN clinical staff as needed.

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

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

• Perform other job-related responsibilities as assigned.

⛳️ Requirements

• An Associate's degree or completion of an accredited registered nursing (RN) degree program is required.

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

• Current and unrestricted Registered Nurse (RN) Licensure in the applicable state(s) is required.

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

• Preferred experience includes med/surgical, emergency acute clinical care, or home health.

• Experience in Utilization Management/Utilization Review is preferred.

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

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

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

• Strong oral and written communication skills are necessary.

• Ability to work independently as well as collaboratively within a team is essential.

• Attention to detail is crucial.

• Proper grammar usage and phone etiquette are expected.

• Strong time management and prioritization skills are required.

• Customer service orientation is essential.

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

• Excellent organizational skills are needed.

• Resilience to change is expected.

🏝️ Benefits

• Performance-related bonuses may be available, based on individual and company results.

• A comprehensive total rewards package is offered.

• Support for employee total well-being is provided.