RN Clinical Care Reviewer - Must have MA RN license Direct UM Experience Preferred!
About The Position
The Clinical Care Reviewer II - Massachusetts processes medical necessity reviews to determine the appropriateness of authorization for health care services. The role also assists with discharge planning, including durable medical equipment and home health services, coordinates care for members, and monitors the delivery of healthcare services. The position completes prospective, concurrent, and retrospective reviews across acute and post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services, and durable medical equipment. The reviewer collaborates with care partners to coordinate transitions to an appropriate level of care, consults a medical director when additional clinical expertise is needed, and follows applicable state and federal regulations, contracts, provider agreements, benefit requirements, and accreditation standards. The role also identifies quality issues and members who may benefit from care management, provides guidance to non-clinical and LPN clinical staff, and supports meetings and special projects as requested. This role is based in a general office environment. Travel is not typically required. Compensation is hourly, with a stated range of $75,200 to $120,500. A performance-based bonus may also be available, and the company describes offering a comprehensive total rewards package.
Requirements
- Associate degree or completion of an accredited registered nursing degree program.
- Three years of clinical experience.
- Current, unrestricted Registered Nurse (RN) licensure in the state or states of practice.
- MCG Certification, or ability to obtain it within six months of hire.
- Proficient data-entry skills and ability to navigate clinical platforms.
- Working knowledge of Microsoft Outlook, Word, and Excel.
- Effective oral and written communication skills.
- Ability to work independently and within a team environment.
- Attention to detail.
- Proper grammar usage and phone etiquette.
- Time management and prioritization skills.
- Customer-service orientation.
- Decision-making and problem-solving skills.
- Strong organizational skills.
- Change resiliency.
Nice To Haves
- Med/surgical, emergency acute clinical care, or home health experience.
- Utilization Management or Utilization Review experience.
- Medicaid, Medicare, or Commercial experience.
Responsibilities
- Complete prospective, concurrent, and retrospective reviews, including acute inpatient and post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services, and durable medical equipment.
- Identify, document, communicate, and coordinate care with collaborative care partners to facilitate transitions to an appropriate level of care.
- Engage with a medical director when additional clinical expertise is needed.
- Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards.
- Identify and refer quality issues to Quality Improvement.
- Identify and refer appropriate members for Care Management.
- Provide guidance to non-clinical staff.
- Provide guidance and support to LPN clinical staff as appropriate.
- Attend medical advisement and State Hearing meetings as requested.
- Assist the Team Leader with special projects or research as requested.
- Perform other job-related duties as requested.
Benefits
- Potential bonus tied to company and individual performance.
- Comprehensive total rewards package.
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What This Job Offers
Job Type
Full-time
Education Level
Associate degree
