Initial Clinical Reviewer II (RN) - PT/Intermittent
Posted on Apr 8, 2019 by Magellan Health
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
TitleInitial Clinical Reviewer II (RN) - PT/Intermittent
Job FamilyClinical Services Group
CountryUnited States of America
FLSA StatusUnited States of America (Non-Exempt)
Recruiting Start Date3/14/2019
Date Requisition Created3/14/2019
EducationAssociates: Nursing (Required), Bachelors
License and Certifications - RequiredASRT - 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 simultaneouslyAt 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.