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

March 5, 2026

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 CareSource, 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 lower 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 <ul><li>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 </li><li>Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care</li><li>Engage with medical director when additional clinical expertise if needed</li><li> Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards </li><li> Identify and refer quality issues to Quality Improvement </li><li> Identify and refer appropriate members for Care Management </li><li> Provide guidance to non-clinical staff </li><li>Provide guidance and support to LPN clinical staff as appropriate</li><li> Attend medical advisement and State Hearing meetings, as requested </li><li> Assist Team Leader with special projects or research, as requested </li><li>Perform any other job related duties as requested. </li></ul>Education And Experience <ul><li>Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program required </li><li>Three (3) years clinical experience required </li><li> Med/surgical, emergency acute clinical care or home health experience preferred </li><li> Utilization Management/Utilization Review experience preferred </li><li> Medicaid/Medicare/Commercial experience preferred </li></ul>Competencies, Knowledge and Skills: <ul><li>Proficient data entry skills and ability to navigate clinical platforms successfully</li><li>Working knowledge of Microsoft Outlook, Word, and Excel </li><li>Effective oral and written communication skills</li><li>Ability to work independently and within a team environment</li><li>Attention to detail</li><li>Proper grammar usage and phone etiquette </li><li>Time management and prioritization skills</li><li>Customer service oriented</li><li>Decision making/problem solving skills</li><li>Strong organizational skills</li><li>Change resiliency </li></ul>Licensure and Certification: <ul><li> Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required </li><li> MCG Certification or must be obtained within six (6) months of hire required </li></ul>Working Conditions: <ul><li>General office environment; may be required to sit or stand for extended periods of time</li><li> Travel is not typically required </li></ul>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 Competencies <ul><li> Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business </li></ul>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.

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...

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