Clinical Care Reviewer II-RN with Compact License

Job Summary:**Looking for RN with Compact License and MA License or Compact License with willingness to obtain MA license**Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members, as well as monitoring the delivery of healthcare services.Essential Functions:Complete prospective, concurrent and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipmentIdentify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of careEngage with medical director when additional clinical expertise if neededMaintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standardsIdentify and refer quality issues to Quality ImprovementIdentify and refer appropriate members for Care ManagementProvide guidance to non-clinical staffProvide guidance and support to LPN clinical staff as appropriateAttend medical advisement and State Hearing meetings, as requestedAssist Team Leader with special projects or research, as requestedPerform any other job related duties as requested.Education and Experience:Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program requiredThree (3) years clinical experience requiredMed/surgical, emergency acute clinical care or home health experience preferredUtilization Management/Utilization Review experience preferredMedicaid/Medicare/Commercial experience preferredCompetencies, Knowledge and Skills:Proficient data entry skills and ability to navigate clinical platforms successfullyWorking knowledge of Microsoft Outlook, Word, and ExcelEffective oral and written communication skillsAbility to work independently and within a team environmentAttention to detailProper grammar usage and phone etiquetteTime management and prioritization skillsCustomer service orientedDecision making/problem solving skillsStrong organizational skillsChange resiliencyLicensure and Certification:Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice requiredMCG Certification or must be obtained within six (6) months of hire requiredWorking Conditions:General office environment; may be required to sit or stand for extended periods of timeTravel is not typically requiredCompensation Range:$62,700.00 - $100,400.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.Compensation Type (hourly/salary):HourlyOrganization Level CompetenciesFostering a Collaborative Workplace CultureCultivate PartnershipsDevelop Self and OthersDrive ExecutionInfluence OthersPursue Personal ExcellenceUnderstand the BusinessThis job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.#LI-JM1Brand=CareSource #J-18808-Ljbffr