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Initial Clinical Reviewer II (RN) - PT/Intermittent

Posted on Apr 8, 2019 by Magellan Health

Maryland Heights, MO 63043
Health Care
Immediate Start
Annual Salary
This is a Intermittent position scheduled up to 19 hours only.

Functions in a clinical review capacity to evaluate all cases, which do not pass the authorization approval process at first call while promoting a supportive team approach with call center staff. Initial clinical reviewers are supported by Physician clinical review staff (MDs) in the utilization management determination process.
  • Reviews charts and analyzes clinical record documentation in order to approve services that meet clinical review criteria.
  • Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for other clinical staff.
  • Conducts regular audits, as assigned, to ensure guidelines are applied appropriately.
  • In states where required, refers all cases that an approval cannot be rendered to the Physician Clinical Reviewer. In States where allowed, will make denial determinations as a specific case warrants.
  • Converses with medical office staff in order to obtain additional pertinent clinical history/information; notifies of approvals and denials, giving clinical rationale.
  • Provides optimum customer service through professional/accurate communication while maintaining NCQA and health plan?s required timeframes.
  • Documents all communication with medical office staff and/or treating provider.
  • Practices and maintains the principles of utilization management by adhering to policies and procedures.
  • Participates in on-going training programs to ensure quality performance in compliance with applicable standards and regulations.

General Job Information


Initial Clinical Reviewer II (RN) - PT/Intermittent



Job Family

Clinical Services Group


United States of America

FLSA Status

United States of America (Non-Exempt)

Recruiting Start Date


Date Requisition Created


Minimum Qualifications


Associates: Nursing (Required), Bachelors

License and Certifications - Required

ASRT - American Society of Radiologic Technologists Certification - Radiology, OT - Occupational Therapist, State Licensure - Care Mgmt, PT - Physical Therapist, State Licensure - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt

License and Certifications - Preferred

Other Job Requirements


- Considerable understanding in the process of care in Radiation Oncology and appropriate documentation and coding of services provided is necessary. Working knowledge of CPT, ICD-9, CCI/OCE edits, hospital and physician office billing is preferred.

Must possess excellent interpersonal and communication skills; Basic computer skills; must be able to talk and type simultaneously

At least 1 year of managed care experience- 5+ years of clinical experience preferred; 1 year of managed care experience preferred.- Knowledge of outpatient imaging procedures preferred.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.

Reference: 689959285