Apply on Employer Site

CareSource · 2 hours ago

Clinical Care Reviewer II - RN - Nevada WFH - Must be Nevada Resident - R10884

United States

Full-time

Remote

Mid Level

3+ years exp

CareSource is a healthcare organization that is seeking a Clinical Care Reviewer II. The role involves processing medical necessity reviews, assisting with discharge planning, and coordinating care for members, while ensuring the delivery of healthcare services is cost-effective.

Health CareMedicalNon Profit

Comp. & Benefits

H1B Sponsor Likely

Hiring Manager

Jennifer McCune

Responsibilities

Complete prospective, concurrent and retrospective review of acute inpatient admissions, post acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment

Coordinate care and facilitate discharge to an appropriate level of care in a timely and cost-effective manner

Refer cases to CareSource Medical Directors when clinical criterial is not met or case conference is needed/appropriate

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

Document, identify and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care

Provide guidance to non-clinical medical management staff

Provide guidance to and assist with oversight of LPN medical management staff

Attend medical advisement and State Hearing meetings, as requested

Assist Team Leader with special projects or research, as requested

Perform any other job-related instructions, as requested

Qualification

Registered Nurse (RN) LicensureUtilization ManagementClinical experienceMCG CertificationMicrosoft OfficeCustomer serviceEffective communicationAttention to detailTime managementOrganizational skills

Required

Completion of an accredited registered nursing (RN) degree program is required

Minimum of three (3) years clinical experience is required

Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice is required

MCG Certification is required or must be obtained within six (6) months of hire

Basic data entry skills and internet utilization skills

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

Familiarity of the healthcare field

Proper grammar usage and phone etiquette

Time management and prioritization skills

Customer service oriented

Decision making/problem solving skills

Strong organizational skills

Change resiliency

Preferred

Med/surgical, emergency acute clinical care or home health experience is preferred

Utilization Management/Utilization Review experience is preferred

Medicaid/Medicare/Commercial experience is preferred

Benefits

You may qualify for a bonus tied to company and individual performance.

A substantial and comprehensive total rewards package.

Company

CareSource

Glassdoor3.8

CareSource provides managed care services to Medicaid beneficiaries.

Founded in 1989

Dayton, Ohio, USA

1001-5000 employees

https://www.caresource.com/

H1B Sponsorship

CareSource has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (9)

2024 (39)

2023 (35)

2022 (22)

2021 (37)

2020 (28)