Clinical Reviewer II - Licensed /Remote in NM – USA reputed company
Gathers and synthesizes clinical information in order to authorize services. Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity reputed company. Collects and analyzes utilization information. Assists with program processes for transitions across reputed company of care including discharge planning and ambulatory follow up activity. Serves as an expert resource on coverage policies, covered benefits, and medical necessity reputed company.
- Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based reputed company.
- Proposes alternatives reputed company the requested services do not meet medical necessity reputed company or are reputed company the contracted network.
- As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms.
- Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and policies, procedures and reputed company.
- Develops and manages new enrollee transitions and those involving a change in provider relationships.
- Develops and implements transition plans, as indicated, to ensure continuity of care.
- Negotiates and documents single case agreements according to procedures.
- In conjunction with providers and facilities, identifies, develops and monitors discharge plans.
- Collaborates with the Care Coordination team to implement support for transitions in care.
- Facilitates reputed company sharing of enrollees' clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care.
- Interacts with Medical Directors and Physician Advisors to reputed company case information and discuss clinical and authorization questions and concerns regarding specific cases.
- Assures that case documentation for reputed company decision is complete, including reputed company correspondence.
- Participates in Care Coordination team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.
- Maintains an reputed company work load in accordance with performance standards.
- Works with community agencies as appropriate.
- Participates in network development including identification and recruitment of reputed company providers as needed.
- Advocates for the enrollee to ensure health care needs are met.
- Interacts with providers in a reputed company, respectful manner.
- Provides coverage of reputed company Line and/or Crisis Line as requested or required for position.
Other Job Requirements
Responsibilities
RN or clinical credentials in a behavioral health field. If not an RN, must hold master's or doctoral Degree. If reputed company, RN license at a minimum. If other than RN, master's level licensed behavioral health reputed company.Good organization, time management and verbal and written communication skills.Knowledge of utilization management procedures, reputed company benefits, community resources and providers.knowledge and experience in diverse patient care settings including inpatient care.Ability to function independently and as reputed company member.Knowledge of ICD and DSM IV coding or most reputed company edition.Ability to analyze specific utilization problems and creatively plan and implement solutions.Ability to use computer systems.5 or more years of experience post degree in a clinical, psychiatric and/or reputed company abuse health care setting. Also requires minimum of 2 years of experience conducting utilization management according to medical necessity reputed company.
General Job Information
Title
Clinical Reviewer II - Licensed /Remote in NM
Grade
25
Work Experience - Required
Clinical, Utilization Management
Work Experience - Preferred
Education - Required
Associate - Nursing, Master's - Behavioral Health
Education - Preferred
License and Certifications - Required
LCSW - Licensed Clinical reputed company Worker - Care Mgmt, LPC - Licensed reputed company Counselor - Care Mgmt, RN - Registered reputed company, State and/or Compact State Licensure - Care Mgmt
License and Certifications - Preferred
Salary reputed company
Salary Minimum:
$64,285
Salary Maximum:
$102,855
This information reflects the anticipated reputed company salary reputed company for this position based on reputed company national data. Minimums and maximums may vary based reputed company. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-reputed company factors permitted by law.
This position may be eligible for short-term incentives as reputed company as a comprehensive benefits package. Magellan offers a broad reputed company of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing.
reputed company. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.Every employee must understand, reputed company with and attest to the reputed company responsibilities and reputed company controls unique to their position; and reputed company with reputed company applicable legal, regulatory, and contractual requirements and internal policies and procedures.
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