GENERAL SUMMARY OF POSITION:
Under the general direction of the Director or designee, the CDRH Clinical Nurse Reviewer is responsible for medical necessity determinations of provider-requested services consistent with established procedural standards and MassHealth program rules and regulations and identifying needs for and providing care coordination for MH members admitted to Chronic Disease and Rehabilitation Hospitals (CDRH). The Clinical Nurse Reviewer will conduct case reviews, record reviews, and medical necessity determinations and will support Board of Hearing appeals as needed. This individual will engage in Quality Improvement and provider activities related to preadmission screening, concurrent and conversion reviews for CDRH, help providers improve their performance, and protect the integrity of the program. The CDRH Clinical Nurse Reviewer may participate in other related quality assurance, quality improvement, program integrity, and review activities. This position reports to the Manager of Clinical Services Operations or designee.