Remote - Registered Nurse (RN) Clinical Care Reviewer - Massachusetts only - Direct UM experience strongly preferred!

📋 Description

• • As a Registered Nurse (RN) Clinical Care Reviewer II, you will play a pivotal role in ensuring the appropriateness and quality of healthcare services provided to our members, operating remotely within Massachusetts.
• • Your primary responsibility will involve conducting comprehensive medical necessity reviews for a wide range of healthcare services, meticulously evaluating authorizations to ensure they align with established clinical guidelines and member needs.
• • This includes processing prospective, concurrent, and retrospective reviews, covering critical areas such as acute inpatient admissions, post-acute care transitions, elective inpatient procedures, outpatient services, homecare provisions, and the necessity of durable medical equipment (DME).
• • You will be instrumental in identifying, documenting, and communicating care needs, proactively engaging with collaborative care partners to facilitate seamless transitions to the most appropriate level of care, thereby optimizing patient outcomes and resource utilization.
• • A key aspect of your role will be to collaborate with Medical Directors when specialized clinical expertise is required to make informed decisions on complex cases.
• • You will be expected to maintain a thorough and up-to-date understanding of all relevant state and federal regulations that govern CareSource, including state contracts, provider agreements, benefit structures, and accreditation standards, ensuring compliance in all review processes.
• • A critical function involves identifying potential quality of care issues and referring them to the Quality Improvement department for further investigation and action.
• • You will also be responsible for identifying members who would benefit from specialized care management programs and referring them accordingly, contributing to proactive health management.
• • Providing clear and accurate guidance to non-clinical staff will be essential, ensuring they understand the clinical context and requirements of the review processes.
• • You will offer guidance and support to LPN clinical staff, leveraging your RN expertise to enhance their understanding and application of clinical review protocols.
• • Participation in medical advisement and State Hearing meetings, as requested, will be part of your role, contributing your clinical insights to these important forums.
• • You will have the opportunity to assist the Team Leader with special projects and research initiatives, contributing to the continuous improvement of our clinical review processes and services.
• • This role demands a high degree of autonomy and the ability to work independently, while also fostering strong collaborative relationships within a team environment.
• • Your keen attention to detail will be paramount in accurately documenting findings, communicating complex clinical information, and ensuring all review criteria are met.
• • You will be a key point of contact, requiring effective oral and written communication skills to interact with providers, internal teams, and potentially members.
• • Strong time management and prioritization skills are essential to manage a demanding caseload efficiently and meet all review deadlines.
• • A customer service-oriented approach is vital, ensuring that interactions are professional, empathetic, and supportive, even in challenging situations.
• • Your decision-making and problem-solving abilities will be crucial in navigating complex clinical scenarios and determining appropriate courses of action.
• • You will be expected to maintain proficiency in data entry and successfully navigate various clinical platforms and electronic health record systems.
• • A solid working knowledge of Microsoft Outlook, Word, and Excel will be necessary for daily tasks, communication, and data management.
• • Adherence to proper grammar usage and professional phone etiquette is expected in all communications.
• • This position offers the flexibility of remote work within Massachusetts, allowing for a better work-life balance while contributing to a leading healthcare organization.
• • You will be part of an organization committed to fostering a collaborative workplace culture, cultivating partnerships, and driving execution to achieve organizational goals.
• • Your role will directly impact the quality of care our members receive, ensuring they access the right services at the right time.
• • You will be empowered to pursue personal excellence and contribute to understanding the business of healthcare delivery from a unique clinical review perspective.