Clinical Care Reviewer II – Unrestricted Massachusetts RN License

CareSource

Clinical Care Reviewer II responsible for processing medical necessity reviews and care coordination in health services. Working remotely with a focus on member health and service delivery.

Posted 7/1/2026full-timeRemote • Massachusetts • 🇺🇸 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 utilization management while maintaining compliance with regulations. Proficient in guiding clinical and non-clinical staff, with strong communication and organizational skills.

Highest-signal resume keywords

Registered Nurse (RN) LicensureUtilization Management/Utilization ReviewClinical ExperienceMCG CertificationData Entry Skills

ATS Keywords

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Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Medical Necessity ReviewsCare CoordinationProspective ReviewsConcurrent ReviewsRetrospective ReviewsClinical Platform NavigationAttention to DetailTime ManagementDecision MakingProblem Solving

Soft Skills

Effective CommunicationCustomer Service OrientationOrganizational SkillsTeam CollaborationIndependent Work

Tools & Technologies

Microsoft OutlookMicrosoft WordMicrosoft Excel

Certifications & Qualifications

Registered Nurse (RN) LicensureMCG Certification

Industry Keywords

MedicaidMedicareCommercial InsuranceQuality ImprovementDMEHome Health ServicesClinical CareEmergency Acute CareDischarge Planning

About the role

Key responsibilities & impact

Responsible for processing medical necessity reviews for appropriateness of authorization for health care services
Assisting with discharge planning activities (i.e. DME, home health services)
Care coordination for members
Monitoring the delivery of healthcare services
Complete prospective, concurrent and retrospective reviews
Identify, document, communicate, and coordinate care
Engage with medical director when additional clinical expertise is needed
Maintain knowledge of regulations governing CareSource
Identify and refer quality issues to Quality Improvement
Provide guidance to non-clinical staff
Provide guidance and support to LPN clinical staff as appropriate
Assist Team Leader with special projects or research
Perform any other job related duties as requested.

Requirements

What you’ll need

Associates of Science (A.S) required
Completion of an accredited registered nursing (RN) degree program 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
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.

Benefits

Comp & perks

Comprehensive total rewards package
Bonuses tied to company and individual performance
Health insurance
Retirement plans