Medical Reviewer

• 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)
• Care coordination for members
• Monitoring the delivery of healthcare services
• Complete prospective, concurrent and retrospective reviews
• Identify, document, communicate, and coordinate care
• Engage with medical director when additional clinical expertise is needed
• Maintain knowledge of regulations governing CareSource
• Identify and refer quality issues to Quality Improvement
• Provide guidance to non-clinical staff
• Provide guidance and support to LPN clinical staff as appropriate
• Assist Team Leader with special projects or research
• Perform any other job related duties as requested.

Clinical Care Reviewer II – Unrestricted Massachusetts RN License

• Monitor journals within your specialty
• Determine whether evidence is appropriate for inclusion in DynaMed
• Collaborate closely with the DynaMed Systematic Literature Surveillance (SLS) team
• Commit to working approximately 1-4 hours per month on a regular basis
• Meet or exceed goals to review evidence in a timely manner

Medical Reviewer jobs in Massachusetts

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Clinical Care Reviewer II – Unrestricted Massachusetts RN License

Contract Medical Literature Reviewer – Cardiology