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Clinical Evaluation and Review
• Receive assigned cases for varied member services (i.e. inpatient, outpatient, DME)
• Review and evaluate cases for medical necessity against medical policy, benefits and/or care guidelines and regulations.
• Complete work in accordance with timeliness, production, clinical quality/accuracy and compliance standards
• Provide notifications to member and/or provider, according to regulatory requirements.
• Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed.
• May coordinate peer-to-peer review upon provider request when members’ health conditions do not meet guidelines
Collaboration and Documentation
• Communicate and collaborate effectively with internal and external clinical/non-clinical staff (including MDs) to coordinate work
• Appropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical information
• Utilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDs.
Hiring Requirements
• RN with 3 years of clinical experience or LPN with 5 years of clinical experience.
• For Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 3 years of clinical experience.
• Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.
Top 3-4 Required Skills:
Nice to have Skills:
Education/Certifications Required: Licensed behavior health provider.
Would like an LCSW Industry Specific Experience – required, ideal, necessary?
What is this role’s main focus for the 1st 90 days? Breakdown of Duties/Typical Day: