Clinical Care Reviewer II – Inpatient MCD, Multi State LOB

CareSource

. Process medical necessity reviews for appropriateness of authorization for health care services .

Posted 9/21/2026full-timeRemote • United StatesMid-LevelSenior💰 $62,700 - $100,400 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in Utilization Management and clinical care coordination, with a strong focus on compliance with state and federal regulations. Proficient in data entry and communication, ensuring effective transitions of care and quality improvement.

Highest-signal resume keywords

Registered Nurse (RN) LicensureUtilization Management ExperienceClinical ExperienceMCG CertificationData Entry Skills

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical Care CoordinationMedical Necessity ReviewsProspective ReviewsConcurrent ReviewsRetrospective ReviewsDischarge PlanningDurable Medical Equipment (DME)Home Health ServicesQuality ImprovementCare Management

Soft Skills

Effective CommunicationAttention to DetailTime ManagementProblem SolvingCustomer Service Orientation

Tools & Technologies

Microsoft OutlookMicrosoft WordMicrosoft ExcelClinical Platforms

Certifications & Qualifications

Registered Nurse (RN) LicensureMCG Certification

Industry Keywords

MedicaidMedicareCommercial InsuranceState ContractsProvider AgreementsAccreditation Standards

About the role

Key responsibilities & impact

Process medical necessity reviews for appropriateness of authorization for health care services
Assist with discharge planning activities, including DME and home health services
Coordinate care for members and monitor delivery of healthcare services
Complete prospective, concurrent, and retrospective reviews for acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services, and durable medical equipment
Identify, document, communicate, and coordinate care to facilitate transitions to an appropriate level of care
Engage with the medical director when additional clinical expertise is needed
Maintain knowledge of state and federal regulations, State Contracts, 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 and support LPN clinical staff
Attend medical advisement and State Hearing meetings as requested
Assist the Team Leader with special projects or research as requested
Perform other job-related duties as requested

Requirements

What you’ll need

Associates of Science (A.S.) completion of an accredited registered nursing (RN) degree program required
Three (3) years clinical experience required
Med/surgical, emergency acute clinical care or home health experience preferred
Utilization Management/Utilization Review experience preferred
Medicaid/Medicare/Commercial experience preferred
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
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

Benefits

Comp & perks

Bonus tied to company and individual performance may be available
Substantial and comprehensive total rewards package
Employee total well-being support