Clinical Care Reviewer II – Ohio RN Licensure Required

CareSource

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

Posted 11/11/2026full-timeRemote • Ohio • 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 medical necessity reviews, care coordination, and compliance with state and federal regulations. Proficient in clinical data management and effective communication within healthcare teams.

Highest-signal resume keywords

Ohio RN LicensureMCG CertificationClinical ExperienceUtilization Management ExperienceProficient Data Entry Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity ReviewsClinical Data ManagementCare CoordinationUtilization ReviewMed/Surgical ExperienceEmergency Acute Clinical CareHome Health ExperienceAttention to DetailTime ManagementDecision-Making Skills

Soft Skills

Effective CommunicationCustomer Service OrientationOrganizational SkillsChange ResiliencyTeam Collaboration

Tools & Technologies

Clinical PlatformsMicrosoft OutlookMicrosoft WordMicrosoft Excel

Certifications & Qualifications

Registered Nurse (RN) LicensureMCG Certification

Industry Keywords

MedicaidMedicareCommercial InsuranceQuality ImprovementProvider AgreementsAccreditation Standards

About the role

Key responsibilities & impact

Process prospective, concurrent, and retrospective medical necessity 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 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 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 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

Ohio RN licensure required
Completion of an accredited registered nursing (RN) degree program required
Associate of Science (A.S.) stated as required
Three (3) years of clinical experience required
Current, unrestricted Registered Nurse (RN) licensure in state(s) of practice required
MCG Certification required or must be obtained within six (6) months of hire
Proficient data entry skills and ability to navigate clinical platforms
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 orientation
Decision-making and problem-solving skills
Strong organizational skills
Change resiliency
Med/surgical, emergency acute clinical care, or home health experience preferred
Utilization Management/Utilization Review experience preferred
Medicaid/Medicare/Commercial experience preferred

Benefits

Comp & perks

Bonus tied to company and individual performance
Comprehensive total rewards package
Employee total well-being support