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Clinical Care Reviewer II – RN, Compact License
CareSource. Conduct prospective, concurrent, and retrospective medical necessity reviews of post-acute admissions and related services .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in conducting medical necessity reviews and discharge planning within post-acute care settings, while maintaining compliance with state and federal regulations. Proficient in effective communication and collaboration with healthcare providers and stakeholders to ensure quality patient care.
Highest-signal resume keywords
Registered Nurse (RN) LicensureUtilization Management ExperienceClinical Experience in Post-Acute CareMCG CertificationEffective Communication Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Necessity ReviewsClinical ReviewsDischarge PlanningData Entry SkillsUtilization ReviewAttention to DetailTime ManagementDecision MakingProblem SolvingOrganizational Skills
Soft Skills
Customer Service OrientedChange ResiliencyAbility to Work IndependentlyTeam CollaborationProper Grammar Usage
Tools & Technologies
Microsoft OutlookMicrosoft WordMicrosoft ExcelInternet Utilization
Certifications & Qualifications
Registered Nurse (RN) LicensureMCG Certification
Industry Keywords
Post-Acute CareMedicaidMedicareClinical CareQuality ImprovementHealthcare RegulationsProvider AgreementsAccreditation Standards
About the role
Key responsibilities & impact- Conduct prospective, concurrent, and retrospective medical necessity reviews of post-acute admissions and related services
- Complete clinical reviews for new and continued stays in post-acute services
- Facilitate timely and cost-effective member discharges to the appropriate level of care
- Refer cases to CareSource Medical Directors when clinical criteria are not met or a case conference is needed
- Maintain knowledge of state and federal regulations, state contracts, provider agreements, policies, benefits, and accreditation standards
- Identify and refer quality issues to the Quality Improvement department
- Refer members receiving post-acute services to Care Management and escalate changing member needs
- Document discharge planning needs and communicate with providers, care managers, discharge planners, Provider Relations, and external stakeholders
- Participate in inter-rater reliability audits
- Attend department huddles, team meetings, and staff meetings
- Provide guidance and support to non-clinical utilization management staff
- Attend medical advisement and State Hearing meetings as requested
- Assist the Team Leader with special projects or research tasks
- Perform other related duties as requested
Requirements
What you’ll need- Completion of an accredited registered nursing (RN) degree program required
- Three (3) years of clinical experience required
- Med/surgical, emergency, acute clinical care or Post Acute Care experience preferred
- Utilization Management/Utilization Review experience preferred
- Medicaid/Medicare/Commercial experience preferred
- 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
- Current, unrestricted Registered Nurse (RN) licensure in state(s) of practice required
- MCG Certification is required or must be obtained within six (6) months of hire
- Availability to work scheduled weekend and holiday hours, including all 365 days
Benefits
Comp & perks- Bonus tied to company and individual performance may be available
- Comprehensive total rewards package
- Employee total well-being support