Clinical Care Reviewer II – MA RN License Required

CareSource

. Complete prospective, concurrent, and retrospective reviews, including acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services, and durable medical equipment .

Posted 11/9/2026full-timeRemote • Massachusetts • United StatesMid-LevelSenior💰 $75,200 - $120,500 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and clinical care coordination, with a strong foundation in state and federal regulations, and the ability to effectively communicate and collaborate with healthcare teams. Proficient in data entry and navigating clinical platforms, ensuring quality care and compliance with accreditation standards.

Highest-signal resume keywords

Registered Nurse (RN) LicensureUtilization Management ExperienceMCG CertificationClinical ExperienceEffective Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization ManagementClinical Care CoordinationData Entry SkillsMed/Surgical ExperienceEmergency Acute Clinical CareHome Health ExperienceAttention to DetailDecision MakingProblem SolvingTime Management

Soft Skills

Effective Oral CommunicationEffective Written CommunicationCustomer Service OrientationOrganizational SkillsChange Resiliency

Tools & Technologies

Microsoft OutlookMicrosoft WordMicrosoft ExcelClinical Platforms

Certifications & Qualifications

Registered Nurse (RN) LicensureMCG Certification

Industry Keywords

MedicaidMedicareCommercial InsuranceQuality ImprovementCare ManagementState ContractsProvider AgreementsAccreditation Standards

About the role

Key responsibilities & impact

Complete prospective, concurrent, and retrospective reviews, including acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services, and durable medical equipment
Identify, document, communicate, and coordinate care with collaborative care partners 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, CareSource requirements, 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
Provide guidance and support to LPN clinical staff as appropriate
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
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
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

Benefits

Comp & perks

Bonus tied to company and individual performance
Substantial and comprehensive total rewards package
Travel is not typically required