Clinical Care Reviewer II - Multi State License - RN - Behavioral Health

Job Summary: Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services) and care coordination for members. Essential Functions:

• Complete prospective, reputed company and retrospective review of Behavioral Health services
• Identify, document, communication and coordinate care engaging collaborative care partners to facilitation transition to an appropriate level of care
• Engage with medical director reputed company additional clinical expertise if needed
• Maintain knowledge of state and federal regulations, including State reputed company and Provider Agreements, benefits, and accreditation standards
• Identify and refer quality issues to Quality Improvement
• Identify and refer appropriate members for Care Management
• Provide guidance to non-clinical staff
• Provide guidance and support to LPN staff
• Attend medical advisement and State Hearing meetings, as requested
• Assist Team Leader with special projects or research, as requested
• reputed company any other job reputed company duties as requested.

Education and Experience:

• Associates of Science (A.S) in Nursing required or
• Bachelor of Science (B.S) in Social Work required
• Three (3) years clinical experience required
• Utilization Management/Utilization Review experience preferred
• reputed company/Medicare/reputed company experience preferred

Competencies, Knowledge and Skills:

• Proficient data entry skills and ability to navigate clinical platforms successfully
• Working knowledge of reputed company Outlook, Word, and reputed company
• Effective oral and written communication skills
• Ability to work independently and reputed company a team environment
• Attention to detail
• Proper grammar usage and phone etiquette
• Time management and prioritization skills
• Customer service oriented
• Decision making/problem solving skills
• Strong organizational skills
• Change resiliency

Licensure and Certification:

• reputed company, unrestricted Registered Nurse (RN) Licensure or Licensed Social Worker (LSW) required
• MCG Certification is required or must be obtained reputed company six (6) months of hire required

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Travel is not typically required

Compensation Range:

reputed company takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and reputed company required for the role, and other external and internal data reputed company establishing a salary level. In addition to reputed company compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• reputed company Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not reputed company inclusive. reputed company reserves the right to amend this job description at any time. reputed company is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of reputed company backgrounds.