[PRINCIPAL RESPONSIBILITIES *: [This position works under the direct supervision of the Supervisor, Community Supports (CS) and is responsible for evaluating the clinical presentation of members in need of Community Supports services.This role utilizes the applicable clinical practice standards/guidelines to determine medical necessity for the service required by the member. [ [The Community Supports (CS) Nurse processes clinical, psychosocial and social determinants of health information to ensure that members receive the appropriate service. The position provides expert guidance to community providers, community based organizations, hospital staff, and other internal and external partners on appropriate resources available to members to achieve the optimal functioning, stability and autonomy. The CS Nurse will be working closely with a team comprised of the Coordinators and external CS Providers in the community. The goal of Community Supports services is to offer services or settings in place of services or settings covered under Medi-Cal and that are medically appropriate, cost-effective alternative to a Medi-Cal Covered service. [ [Principal responsibilities include:]{noto="" sans=""}]{noto="" sans=""}]{noto="" sans=""}]{noto="" sans=""}]{noto="" sans=""}*]{noto="" sans=""}

Review of prospective, inpatient or retrospective medical records of services for medical necessity

Consultation with the Alliance Medical Director to validate patient acuity and plan of care as needed;

Extrapolate and summarize medical information for Medical Director, consultants or other external review entities.

Apply clinical medical necessity guidelines, policy and procedures, and EOC benefit guidelines.

Prepare recommendations to either approve or deny, and forward recommendations for denial of payment to Medical Director for review.