CareSource Nursing Jobs and Careers

Hybrid Registered Nurse (RN) Clinical Care Manager - Boston

$90,000 - $120,000 / year

Job Summary: The Clinical Care Manager-Massachusetts is a community based registered nurse responsible for providing monitoring, follow-up and clinical care management to dually-eligible enrollees with complex medical, behavioral and social care needs. This position focuses on integrating health services and community resources to coordinate enrollee care for improve health outcomes and enhanced quality of life. Essential Functions: Engage with the enrollee in their homes and other community settings to establish an effective, complex care management relationship, while considering the cultural and linguistic needs of each member. Function as a liaison between healthcare providers, community resources, and enrollees to ensure seamless communication and care transitions. Perform required assessments on a timely basis, including but not limited to Comprehensive Assessment, MDS-HC (or successor) Functional Assessments, and Crisis and Risk Assessments Engage enrollees in care plan development and implementation, providing routine updates as the enrollee’s status changes Lead the interdisciplinary care team (ICT) and collaborate with peers both internal and external to the organization, to create holistic care plans that address medical and non-medical needs. Oversee enrollee utilization of long-term services and supports, ensuring appropriate systems are in place for enrollees to remain in the location of their choice Assist members in accessing community resources, including housing, transportation, food assistance, and social services. Educate members about their benefits and available services under both Medicare and Medicaid. Provide education to members and their families about managing chronic conditions, medication adherence, and preventive care. Promote healthy lifestyle choices and self-management strategies. Assist enrollees in preventative health strategies, including gap closure Follow up with members after hospitalizations or significant health events to ensure continuity of care and prevent readmissions. Work closely with primary care physicians, specialists, and other healthcare providers to coordinate care and share relevant information. Coordinate with community-based organizations, other stakeholders/entities, state agencies, and other service providers to ensure coordination and avoid duplication of services. Advocate for the needs and preferences of enrollees within the healthcare system. Evaluate member satisfaction through open communication and monitoring of concerns or issues. Regular travel to conduct member, provider and community-based visits as required Report abuse, neglect, or exploitation of older adults and adults with disabilities as a mandated reporter as required by State law. Adherence to NCQA and Care Management standards Performs any other job related duties as requested. Education and Experience: Associates of Science (A.S) degree in nursing from an accredited nursing program required or Master's degree in social work or mental health counseling and independent license required Three (3) years of experience as a Registered Nurse/BH Clinician or One (1) year as a Registered Nurse/BH Clinician with two (2) years of experience working with people with complex medical, behavioral and social needs as an LPN, CHW, MA required Prior experience in care coordination, case management, or working with dual-eligible populations preferred Medicaid and/or Medicare managed care experience preferred Competencies, Knowledge and Skills: Intermediate proficiency level with Microsoft Office, including Outlook, Word and Excel. Understanding of Medicare and Medicaid programs, as well community resources and services available to dual-eligible beneficiaries. Strong interpersonal and communication skills to effectively engage with members, families, and healthcare providers Ability to manage multiple cases and priorities while maintaining attention to detail. Adhere to code of ethics that aligns with professional practice. Awareness of and sensitivity to the diverse backgrounds and needs of the populations served Decision making and problem-solving skills. Ability to function independently and effectively as part of an interdisciplinary team Strong and effective communication skills, both written and verbal Strong interpersonal and customer relations skills Strong customer service skills Licensure and Certification: Current unrestricted clinical license in the Commonwealth of Massachusetts as a Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), Licensed Independent Clinical Social Worker (LISCW), or a Licensed Mental Health Counselor (LMHC) required Case Management Certification is highly preferred Must have valid driver's license, vehicle and verifiable insurance. Employment in this position is conditional pending successful clearance of a driver’s license record check. If the driver’s license record results are unacceptable, the offer will be withdrawn or, if employee has started employment in position, employment in this position will be terminated To help protect our employees, members, and the communities we serve from acquiring communicable diseases, Influenza vaccination is a requirement of this position. CareSource requires annual proof of Influenza vaccination for designated positions during Influenza season (October 1 – March 31) as a condition of continued employment. Employees hired during Influenza season will have thirty (30) days from their hire date to complete the required vaccination and have record of immunization verified. CareSource adheres to all federal, state, and local regulations. CareSource provides reasonable accommodations to qualified individuals with disabilities or medical conditions, sincerely held religious beliefs, or as required by state law to enable the employee to perform the essential functions of the position. Request for accommodations will be completed through an interactive review process. Working Conditions: This is a mobile position, meaning that regular travel to different work locations, including homes, offices or other public settings, is essential. Will be exposed to weather conditions typical of the location and may be required to stand and/or sit for long periods of time. Must reside in the same territory they are assigned to work in; exceptions may be considered, due to business need May be required to travel greater than 50% of time to perform work duties. Required to use general office equipment, such as a telephone, photocopier, fax machine, and computer Flexible hours, including possible evenings and/or weekends as needed to serve the needs of our members Must live within commutable distance to the Commonwealth of Massachusetts Over 50% (Mobile) Routine travel required Compensation Range: $90,000 - $120,000 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 (hourly/salary): Salary Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business 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.

Clinical Care Reviewer II - RN - MultiState License

CareSource Dayton, OH

$62,700 - $100,400 / year

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, 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 Competencies, Knowledge and Skills: 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 Licensure and Certification: 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 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 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 (hourly/salary): Hourly Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business 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

Medical Director(Must Live In Massachusetts)

CareSource Hull, MA

$195,200 - $341,600 / year

Job Summary: The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members. Essential Functions: Provide prior authorization medical reviews, consultation and clinical review services Participate in peer-to-peer discussions Provide provider education, training, data sharing, performance evaluations and orientation to the plan Conduct clinical reviews for designated CareSource members as requested Provide physician review for clinical appeals cases Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns Participate in development of policies and procedures Participates in quality improvement initiatives, case management activities and member safety activities (i.e. incident management Provide cross-coverage for other Medical Directors and/or markets, as needed Oversight and quality improvement activities associated with case management activities Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate Participate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards Participate in the development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives Collaborate with market/product leaders to help define market strategy Community collaborative participation Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs Perform any other job related instructions, as requested Education and Experience: Completion of an accredited Medical Degree program as a medical doctor (MD) or Doctor of Osteopathic (DO) medicine is required Successful completion of a residency training program, preferably in primary care is required Minimum of five (5) years of clinical practice experience is required Managed care medical review/medical director experience is preferred Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management is preferred Competencies, Knowledge and Skills: Basic Microsoft Word skills Excellent communication skills, both written and oral Ability to work well independently and within a team environment Ability to create strong relationships with Providers and Members High ethical standards Attention to detail Critical listening and systematic thinking skills Ability to maintain confidentiality and act in the company’s best interest Ability to act with diplomacy and sensitivity to cultural diversity Decision making/problem solving skills Conflict resolution skills Strong sense of mission and commitment of time, effort and resources to the betterment of the communities served Licensure and Certification: Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements is required Board Certification, preferably in primary care specialty is required Re-certification, as required by specialty board, must be maintained (exceptions may be granted by Chief Medical Officer) MCG Certification is required or must be obtained within six (6) months of hire Working Conditions: General office environment; may be required to sit or stand for extended periods of time May be required to work evenings/weekends May be required to travel to fulfill duties of position Compensation Range: $195,200.00 - $341,600.00 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 (hourly/salary): Salary Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business 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-SW2

Medical Director(Must Live In Massachusetts)

CareSource Hull, MA

$195,200 - $341,600 / year

Job Summary: The Medical Director is responsible for supporting staff by providing training, clinical consultation, and clinical case review for members. Essential Functions: Provide prior authorization medical reviews, consultation and clinical review services Participate in peer-to-peer discussions Provide provider education, training, data sharing, performance evaluations and orientation to the plan Conduct clinical reviews for designated CareSource members as requested Provide physician review for clinical appeals cases Participate in the evaluation and investigations of cases suspected of fraud, abuse, and quality of care concerns Participate in development of policies and procedures Participates in quality improvement initiatives, case management activities and member safety activities (i.e. incident management Provide cross-coverage for other Medical Directors and/or markets, as needed Oversight and quality improvement activities associated with case management activities Assist in the review of utilization data to identify variances in patterns, and provide feedback and education to MCP staff and providers as appropriate Participate in the development, implementation and revision of the clinical care standards and practice guidelines ensuring compliance with nationally accepted quality standards Participate in the development, implementation and revision of the Quality Improvement Plan and corporate level quality initiatives Collaborate with market/product leaders to help define market strategy Community collaborative participation Support of regulatory and accreditation functions (eg. CMS, State, NCQA and URAC) and compliance for all programs Perform any other job related instructions, as requested Education and Experience: Completion of an accredited Medical Degree program as a medical doctor (MD) or Doctor of Osteopathic (DO) medicine is required Successful completion of a residency training program, preferably in primary care is required Minimum of five (5) years of clinical practice experience is required Managed care medical review/medical director experience is preferred Bachelor's or Master's degree in Business Administration, Operational Excellence, Healthcare Administration or Medical Management is preferred Competencies, Knowledge and Skills: Basic Microsoft Word skills Excellent communication skills, both written and oral Ability to work well independently and within a team environment Ability to create strong relationships with Providers and Members High ethical standards Attention to detail Critical listening and systematic thinking skills Ability to maintain confidentiality and act in the company’s best interest Ability to act with diplomacy and sensitivity to cultural diversity Decision making/problem solving skills Conflict resolution skills Strong sense of mission and commitment of time, effort and resources to the betterment of the communities served Licensure and Certification: Current, unrestricted license to practice medicine in state of practice as necessary to meet regulatory requirements is required Board Certification, preferably in primary care specialty is required Re-certification, as required by specialty board, must be maintained (exceptions may be granted by Chief Medical Officer) MCG Certification is required or must be obtained within six (6) months of hire Working Conditions: General office environment; may be required to sit or stand for extended periods of time May be required to work evenings/weekends May be required to travel to fulfill duties of position Compensation Range: $195,200.00 - $341,600.00 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 (hourly/salary): Salary Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business 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-SW2

Clinical Care Reviewer II - Multi State License - RN - Behavioral Health

CareSource

$62,700 - $100,400 / year

Job Summary: Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services) and care coordination for members. Essential Functions: Complete prospective, concurrent and retrospective review of Behavioral Health services Identify, document, communication and coordinate care engaging collaborative care partners to facilitation transition to an appropriate level of care Engage with medical director when additional clinical expertise if needed Maintain knowledge of state and federal regulations, including 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 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 duties as requested. Education and Experience: Associates of Science (A.S) in Nursing required or Bachelor of Science (B.S) in Social Work required Three (3) years clinical experience required 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 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 Licensure and Certification: Current, unrestricted Registered Nurse (RN) Licensure or Licensed Social Worker (LSW) required MCG Certification is required or must be obtained within 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 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 (hourly/salary): Hourly Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business 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