Clinical Care Reviewer II - RN - PST Hours
Carson City, Nevada, United States of America
- Job ID
- R13286
- Category
- Utilization Management
- Date posted
- 07/28/2026
- Location
- Carson City, Nevada
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:
Education and Experience:
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
#LI-JM1
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, concurrent 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 when additional clinical expertise if needed
- 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
- 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
- Perform any other job related 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
- 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
- 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
- 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 CareSource 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 latitude required for the role, and other external and internal data when establishing a salary level. In addition to base 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
HourlyCompetencies
Organization Level Competencies - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the BusinessThis job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
#LI-JM1
Related Content
-
-
Our Culture
Embark on a career where you can improve the health and well-being of our members and communities. Learn about CareSource culture and search our jobs.
Learn More -
Discover our Benefits
Learn more about how we support the physical, financial, and emotional well-being of our valued employees.
Learn More
-
Community Health Worker - Ohio Mobile
- Dayton, Ohio; Cleveland, Ohio; Toledo, Ohio; Akron, Ohio; Canton, Ohio; Cincinnati, Ohio; Lisbon, Ohio; Medina, Ohio; Ravenna, Ohio; Warren, Ohio; Wooster, Ohio; Circleville, Ohio; Hamilton, Ohio; Wilmington, Ohio; Bowling Green, Ohio; Chardon, Ohio; Painesville, Ohio; Elyria, Ohio; Youngstown, Ohio; Delaware, Ohio; London, Ohio; Marysville, Ohio; Batavia, Ohio; Lebanon, Ohio; Port Clinton, Ohio; West Jefferson, Ohio; Lancaster, Ohio; Bryan, Ohio; Defiance, Ohio; Fremont, Ohio; Napoleon, Ohio; Newark, Ohio; Paulding, Ohio; Sandusky, Ohio; Springfield, Ohio; Washington Court House, Ohio; Wauseon, Ohio; Xenia, Ohio
-
Life Services Life Coach III
- Jackson, Mississippi
-
Provider Engagement Specialist III- Mississippi- Central West and Coastal Region
- Jackson, Mississippi
You have not viewed any jobs yet.
You have not saved any jobs yet.