Clinical Care Reviewer II - RN - MSL

CareSource Management Group Company

Job Overview

Location

Remote

Job Type

Full-time

Full Job Description

📋 Description

• The Clinical Care Reviewer II - RN - MSL role is essential to ensuring that CareSource members receive appropriate, timely, and medically necessary healthcare services through rigorous utilization review processes. This position directly impacts patient outcomes by evaluating the necessity and efficiency of care across inpatient, outpatient, home health, and durable medical equipment services, helping to prevent unnecessary utilization while safeguarding access to needed treatments.
• The role supports CareSource’s mission of improving health equity and quality by coordinating care transitions, identifying gaps in service delivery, and collaborating with clinical and non-clinical teams to promote seamless, member-centered care—particularly for Medicaid, Medicare, and commercial populations.
• Day-to-day responsibilities include conducting prospective, concurrent, and retrospective medical necessity reviews for acute inpatient admissions, post-acute care, elective procedures, home health services, and durable medical equipment (DME) requests.
• The reviewer identifies, documents, and communicates care coordination needs, engaging collaborative partners such as primary care providers, specialists, and social workers to facilitate safe and appropriate transitions between levels of care (e.g., hospital to home or skilled nursing facility).
• When complex clinical questions arise, the reviewer engages with the Medical Director for expert consultation to ensure evidence-based decision-making aligned with MCG guidelines and clinical standards.
• Maintaining up-to-date knowledge of state and federal regulations, CareSource contracts, provider agreements, and accreditation standards (such as NCQA and URAC) is critical to ensure compliance and accurate benefit determinations.
• The reviewer identifies potential quality of care concerns and refers them to the Quality Improvement department, while also flagging members who may benefit from enrollment in Care Management programs for ongoing support.
• Providing mentorship and guidance to non-clinical staff and LPN clinical team members is a key function, helping to elevate overall team competency and consistency in clinical documentation and decision-making.
• Participation in medical advisement committees and State Hearing meetings, as requested, allows the reviewer to contribute to policy development and appeal processes.
• The role includes supporting the Team Leader with special projects, research initiatives, or process improvements aimed at enhancing utilization management efficiency and member outcomes.
• All duties are performed in a remote office environment requiring strong self-direction, time management, and proficiency with clinical platforms, Microsoft Office Suite (Outlook, Word, Excel), and electronic health record systems.
• The position demands exceptional attention to detail, strong organizational abilities, effective oral and written communication, and the capacity to work both independently and collaboratively within a multidisciplinary team.
• Success in this role requires sound decision-making, problem-solving skills, customer service orientation, and resilience in adapting to evolving healthcare policies and utilization management practices.
• The Clinical Care Reviewer II will develop deep expertise in utilization management, clinical guidelines (particularly MCG), regulatory compliance, and care coordination—skills that are highly transferable across healthcare insurance, hospital systems, and consulting environments.
• Over time, the incumbent can advance into senior reviewer, team lead, or care management roles, gaining leadership experience while contributing to improved healthcare affordability, quality, and equity for underserved populations served by CareSource.

🎯 Requirements

• Current, unrestricted Registered Nurse (RN) licensure in the state(s) of practice is required.
• Completion of an accredited Associate of Science (A.S.) in Nursing or higher nursing degree is required.
• Minimum of three (3) years of recent clinical experience in med/surgical, emergency acute care, or home health settings is required.
• MCG Certification is required, or must be obtained within six (6) months of hire.
• Proficiency in data entry and navigation of clinical platforms (e.g., InterQual, MCG, or similar utilization management tools) is required.
• Working knowledge of Microsoft Outlook, Word, and Excel is required for documentation, reporting, and communication.

🏖️ Benefits

• Competitive hourly compensation ranging from $62,700 to $100,400 annually, based on education, experience, and role scope.
• Eligibility for performance-based bonuses tied to individual and company achievements.
• Access to a comprehensive total rewards package including health, dental, vision, and wellness programs supporting total well-being.
• Opportunities for professional development, including support for obtaining MCG Certification and other relevant credentials.
• Remote work flexibility enabling a balanced work-life integration while serving members across multiple states.
• Exposure to organizational leadership competencies such as fostering collaboration, driving execution, and developing self and others—preparing for future advancement.

Skills & Technologies

Remote

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CareSource Management Group Company

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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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