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
Monitoring the delivery of healthcare services
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
Provide guidance to non-clinical staff
Provide guidance and support to LPN clinical staff as appropriate

Completion of an accredited registered nursing (RN) degree program required
Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required
Three (3) years clinical experience required
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
Attention to detail
Proper grammar usage and phone etiquette
Time management and prioritization skills

Clinical Care Reviewer II – Unrestricted Massachusetts RN License

Key skills