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Clinical Review Specialist

1 month ago

Detroit, Michigan, United States LanceSoft Full time
Job Summary

We are seeking a highly skilled Clinical Review Specialist to join our team at LanceSoft. As a key member of our post-acute care review team, you will be responsible for ensuring the medical necessity of services provided to our members.

Key Responsibilities:

  • Conduct prospective, concurrent, and retrospective medical necessity reviews of post-acute care services
  • Use established medical policy and guidelines, including InterQual and MCG, to inform review decisions
  • Coordinate care through the healthcare continuum, including member outreach and support
  • Develop and implement discharge readiness plans for members transitioning from post-acute care to lower levels of care

Requirements:

  • Bachelor's degree in nursing, allied health, business, or related field
  • Two to four years of clinical experience, including post-acute care, home care, acute patient care, discharge planning, case management, and utilization review
  • Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes
  • One year health insurance plan experience or managed care environment preferred
  • Registered Nurse with current unrestricted Michigan Registered Nurse license required

LanceSoft is an equal opportunity employer and prohibits discrimination and harassment of any kind. We are committed to creating a diverse and inclusive work environment that values and respects all employees.