Job Overview
Location
Remote
Job Type
Full-time
Category
Product Management
Date Posted
June 25, 2026
Full Job Description
đź“‹ Description
- • Perform prospective, concurrent, and retrospective medical necessity reviews for acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services, and durable medical equipment (DME)
- • Assess appropriateness of healthcare service authorizations in alignment with state and federal regulations, CareSource contracts, provider agreements, benefits, and accreditation standards
- • Coordinate care transitions by identifying, documenting, and communicating member needs to collaborative care partners, including facilitating discharge planning for DME and home health services
- • Engage medical directors for clinical consultation when additional expertise is required to support review decisions
- • Identify and refer members with complex needs to Care Management programs to ensure continuity and quality of care
- • Detect and escalate quality issues to the Quality Improvement team for review and resolution
- • Provide clinical guidance and support to non-clinical staff and LPN clinical personnel to ensure consistent application of care standards
- • Participate in medical advisement and State Hearing meetings as requested to represent clinical review positions
- • Assist Team Leaders with special projects, research initiatives, and operational tasks as assigned
- • Maintain accurate documentation and utilize clinical platforms to ensure compliance and data integrity
- • Demonstrate proficiency in data entry and navigation of clinical systems to support timely and accurate review outcomes
- • Apply strong communication skills—both oral and written—to interact with providers, internal teams, and external stakeholders
- • Manage time effectively, prioritize multiple concurrent reviews, and maintain attention to detail in high-volume environments
- • Uphold professional phone etiquette, proper grammar, and customer service standards in all member and provider interactions
- • Adapt to changing policies, regulations, and organizational priorities with resilience and a solutions-oriented mindset
- • Operate independently while contributing effectively within a team-based structure to meet departmental goals
- • Perform additional job-related duties as requested to support operational needs and organizational objectives
🎯 Requirements
- • Current, unrestricted Registered Nurse (RN) licensure in state(s) of practice
- • Associate of Science (A.S.) degree from an accredited registered nursing (RN) program
- • Three (3) years of clinical experience required
- • MCG Certification within six (6) months of hire
- • Proficient data entry skills and ability to navigate clinical platforms
- • Working knowledge of Microsoft Outlook, Word, and Excel
🏖️ Benefits
- • Compensation range of $62,700.00 - $100,400.00
- • Eligibility for bonus tied to company and individual performance
- • Comprehensive total rewards package including well-being initiatives
- • Remote work arrangement with no typical travel requirements
- • General office environment with flexibility to sit or stand during extended work periods
- • Opportunity to work in a collaborative, inclusive culture focused on belonging
Skills & Technologies
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About CareSource Management Group Company
CareSource is a nonprofit, multi-state managed care organization headquartered in Dayton, Ohio. Founded in 1989, it administers Medicaid, Medicare Advantage, and Marketplace health plans serving over two million members in Ohio, Kentucky, Indiana, West Virginia, and Georgia. The company focuses on improving health outcomes for low-income and vulnerable populations through integrated care management, behavioral health services, and social determinants programs.
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