Clinical Reviewer

• Process prospective, concurrent, and retrospective medical necessity reviews for health care services
• Review acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services, and durable medical equipment
• Identify, document, communicate, and coordinate care with collaborative care partners
• Facilitate transitions to an appropriate level of care
• Engage with the medical director when additional clinical expertise is needed
• Maintain knowledge of state and federal regulations, CareSource contracts, 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 and support LPN clinical staff
• Attend medical advisement and State Hearing meetings as requested
• Assist the Team Leader with special projects or research as requested
• Perform other job-related duties as requested

Clinical care reviewer processing medical necessity reviews for CareSource health plan members

Clinical Care Reviewer II – Unrestricted Massachusetts RN License

Clinical care reviewer processing medical necessity reviews and coordinating care for CareSource health plan members. Supporting authorization, discharge planning, quality improvement, and care management referrals.

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Clinical Care Reviewer II – Unrestricted Massachusetts RN License