CareSource

Clinical Reviewer II, RN

CareSource

full-time

Posted on:

Origin:  • 🇺🇸 United States • Ohio

Visit company website
✨ AI Apply
Manual Apply

Salary

💰 $61,500 - $98,400 per year

Job Level

Mid-LevelSenior

About the role

  • Complete prospective, concurrent and retrospective review of acute inpatient admissions, post acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment
  • Coordinate care and facilitate discharge to an appropriate level of care in a timely and cost-effective manner
  • Refer cases to CareSource Medical Directors when clinical criterial is not met or case conference is needed/appropriate
  • Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards
  • Identify and refer quality issues to Quality Improvement
  • Identify and refer appropriate members for Care Management
  • Document, identify and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care
  • Provide guidance to non-clinical medical management staff
  • Provide guidance to and assist with oversight of LPN medical management staff
  • Attend medical advisement and State Hearing meetings, as requested
  • Assist Team Leader with special projects or research, as requested
  • Perform any other job-related instructions, as requested

Requirements

  • Completion of an accredited registered nursing (RN) degree program is required
  • Minimum of three (3) years clinical experience is required
  • Med/surgical, emergency acute clinical care or home health experience is preferred
  • Utilization Management/Utilization Review experience is preferred
  • Medicaid/Medicare/Commercial experience is preferred
  • Military affiliation or TRICARE experience is preferred
  • Current, unrestricted RN licensure in state(s) of practice is required
  • MCG Certification is required or must be obtained within six (6) months of hire
No results yet. Try adjusting filters above.