Clinical Reviewer

• Process prospective, concurrent, and retrospective medical necessity reviews for health care services
• Assist with discharge planning activities, including DME and home health services
• Coordinate care for members and monitor delivery of healthcare services
• Complete reviews for 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 to 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 requirements, State 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 as appropriate
• 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

Explore RN Clinical Care Reviewer – MA RN License Required, Direct UM… at CareSource. Review requirements and application details.

RN Clinical Care Reviewer – MA RN License Required, Direct UM Experience Preferred

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