RN Clinical Care Reviewer – MA RN License Required, Direct UM Experience Preferred

CareSource

. Process prospective, concurrent, and retrospective medical necessity reviews for health care services .

Posted 11/10/2026full-timeRemote • Massachusetts • United StatesMid-LevelSenior💰 $75,200 - $120,500 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical necessity reviews, care coordination, and compliance with state and federal regulations. Proficient in guiding clinical and non-clinical staff while maintaining high standards of patient care and documentation.

Highest-signal resume keywords

Registered Nurse (RN) LicensureMCG CertificationUtilization Management ExperienceClinical ExperienceEffective Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity ReviewsCare CoordinationData Entry SkillsClinical Platform NavigationAttention to DetailTime ManagementDecision MakingProblem SolvingOrganizational SkillsDischarge Planning

Soft Skills

Effective Oral CommunicationEffective Written CommunicationCustomer Service OrientationAbility to Work IndependentlyTeam Collaboration

Tools & Technologies

Microsoft OutlookMicrosoft WordMicrosoft Excel

Certifications & Qualifications

Registered Nurse (RN) LicensureMCG Certification

Industry Keywords

MedicaidMedicareCommercial InsuranceQuality ImprovementDurable Medical EquipmentHome Health ServicesAcute Inpatient AdmissionsPost-Acute AdmissionsElective Inpatient AdmissionsProvider Agreements

About the role

Key responsibilities & impact

Process prospective, concurrent, and retrospective medical necessity reviews 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 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 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 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

Associates degree or 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
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 may be available
Comprehensive total rewards package
Employee total well-being support