Job DescriptionThis position is a key member of the utilization management team, and provides timely chiropractic review of service requests. Routinely interacts with Chiropractors, leadership and management staff, other Chiropractic and Physician reviewers and staff when Chiropractic input is needed.
- Perform case reviews, both approvals and denials, for Chiropractic requests.
- Discuss determinations with requesting Chiropractors, when available, within the regulatory timeframe of the request by phone or fax.
- Provide the clinical rationale for standard and expedited chiropractic appeals.
- Provide assistance and act as a resource to Initial Clinical Reviewers as need to discuss cases and problems.
- Utilize Clinical Guidelines and parameters to assure consistency in the DC review process to reflect appropriate utilization and compliance with policies/procedures as well as URAC and NCQA elements. Ensure documentation meets all requirements.
- Participate in on-going training and inter-rate reliability process.
- Assist the Chiropractic Director in research activities/questions related to utilization management process, interpretation, guidelines and/or system support.
- Review appeal cases and/or attends hearings for discussions of utilization management decisions.
General Job Information
TitleChiropractic Clinical Reviewer - New Jersey or Deleware
Job FamilyClinical Services Group
CountryUnited States of America
FLSA StatusUnited States of America (Non-Exempt)
Recruiting Start Date5/10/2019
Date Requisition Created5/10/2019
License and Certifications - RequiredDC - Doctor of Chiropractic, State Licensure - Care Mgmt
License and Certifications - Preferred
Other Job Requirements
- Working knowledge of Commission of Insurance, URAC, NCQA, HIPAA, state and federal requirements regarding UM/QM/Credentialing.
- 5+ years of full time experience as a practicing Chiropractor.
- Graduate of a Chiropractic College accredited by the Council on Chiropractic Education and have a current, unrestricted chiropractic license in the assigned state.
- Must be certified by the National Board of Chiropractic Examiners.
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.
“I receive a high level of support from our Senior Management Team to execute on our vision. They are always accessible and approachable, something I’ve found to be very unique to Magellan.”