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CareSource · 2 weeks ago

Clinical Care Reviewer - RN - Indiana Licensed - R11357

Indiana, United States

Full-time

Onsite

Mid Level

$63K/yr - $100K/yr

3+ years exp

CareSource is seeking a Clinical Care Reviewer II who will be responsible for processing medical necessity reviews and assisting with care coordination for members. The role involves monitoring healthcare service delivery and engaging with care partners to facilitate transitions to appropriate care levels.

Health CareMedicalNon Profit

Comp. & Benefits

H1B Sponsor Likely

Responsibilities

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

Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care

Engage with medical director when additional clinical expertise if needed

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

Provide guidance to non-clinical staff

Provide guidance and support to LPN clinical staff as appropriate

Attend medical advisement and State Hearing meetings, as requested

Assist Team Leader with special projects or research, as requested

Perform any other job related duties as requested

Qualification

Registered Nurse (RN) LicensureUtilization Management experienceClinical experienceMCG CertificationData entry skillsMicrosoft Office proficiencyCustomer service orientationChange resiliencyEffective communicationTeamworkAttention to detailTime managementProblem solvingOrganizational skills

Required

Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program required

Three (3) years clinical experience required

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

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

Proficient data entry skills and ability to navigate clinical platforms successfully

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

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 preferred

Utilization Management/Utilization Review experience preferred

Medicaid/Medicare/Commercial experience preferred

Benefits

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

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 (30)

2024 (39)

2023 (35)

2022 (21)

2021 (37)

2020 (28)