Behavioral Health Clinical Reviewer
The Clinical Reviewer will use clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking, and decision-making skills to determine medical appropriateness while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA, URAC, and other regulatory standards.
Responsibilities:
- Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care; determine if the medical record documentation supports the need for services.
- Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring the reason for the denial is described in sufficient detail in correspondence.
- Abstracts review related data/information accurately and timely on appropriate review tool by the appropriate means. Accurate and timely submission of all administrative and review related documents to appropriate parties.
- Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building in order to facilitate the review process.
- Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
- Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, and adherence to HIPAA policies.
- Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following Client policies, procedures, and guidelines.
- Actively cross-trains to perform the duties of others within the Client network to provide a flexible workforce to meet client/consumer needs.
Requirements:
- Active unrestricted license in Virginia: Psychiatric/Mental Health RN, Licensed Clinical Social Worker (LCSW), Licensed Mental Health Professional (LMHP), or Licensed Marriage and Family Therapist (LMFT),
- Knowledge of InterQual or ASAM criteria
- Knowledge of current NCQA/URAC standards
- 2+ years of Utilization Review and/or Prior Authorization experience
- 3+ years of direct experience in a clinical setting or other applicable State Clinical experience.
- Experience in Community Mental Health, Crisis Mental Health, Residential Services, or Inpatient Behavioral health/Psychology
Required Skills:
- Excellent verbal and written communication skills
- Ability to problem solve.
- Proficient computer skills, including Microsoft Office.
- Ability to provide technical consultation and policy interpretation.
- Excellent customer services
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