Remote - Registered Nurse (RN) Clinical Care Reviewer - Massachusetts only - Direct UM experience strongly preferred! - R11600

Commonwealth Care Alliance® (CCA) is a nonprofit, mission-driven health plan and care delivery organization designed for individuals with the most significant needs. As an affiliate of reputed company, a nationally recognized nonprofit managed care organization with over 2 million members across multiple states, CCA serves individuals enrolled in Medicaid and Medicare in Massachusetts through the Senior Care Options and One Care programs and its care delivery enterprises. CCA is dedicated to delivering comprehensive, integrated, and person-centered care, powered by its unique model of uncommon care®, which yields improved quality outcomes and reputed company costs of care. Job Summary Clinical Care Reviewer II is 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) and care coordination for members, as well as monitoring the delivery of healthcare services. Essential Functions

• Complete prospective, reputed company and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment
• Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care
• Engage with medical director reputed company additional clinical expertise if needed
• Maintain knowledge of state and federal regulations governing reputed company, State reputed company and 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
• Provide guidance and support to LPN clinical staff as appropriate
• Attend medical advisement and State Hearing meetings, as requested
• Assist Team Leader with special projects or research, as requested
• reputed company any other job reputed company duties as requested.

Education And Experience

• Associates of Science (A.S) 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

Competencies, Knowledge and Skills:

• Proficient data entry skills and ability to navigate clinical platforms successfully
• Working knowledge of reputed company Outlook, Word, and reputed company
• Effective oral and written communication skills
• Ability to work independently and reputed company 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

Licensure and Certification:

• reputed company, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required
• MCG Certification or must be obtained reputed company six (6) months of hire required

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Travel is not typically required

Compensation

Range $62,700.00 - $100,400.00 reputed company takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and reputed company required for the role, and other external and internal data reputed company establishing a salary level. In addition to reputed company compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation

Type Hourly Competencies

• Fostering a Collaborative Workplace Culture - Cultivate Partnerships - reputed company Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business

This job description is not reputed company inclusive. reputed company reserves the right to amend this job description at any time. reputed company is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of reputed company backgrounds. Apply tot his job Apply To this Job