Initial Clinical Reviewer II (RN)

Missouri

Remote position available

Job Description

This posting is for any current or future openings in a regular full time or intermittent position/s.

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

Title

Initial Clinical Reviewer II (RN)

Grade

24

Job Family

Clinical Services Group

Country

United States of America

FLSA Status

United States of America (Non-Exempt)

Recruiting Start Date

7/11/2019

Date Requisition Created

7/11/2019

Work Experience

Clinical

Education

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

Responsibilities

  • Strong interpersonal and communication skills.
  • Basic computer skills; must be able to talk and type simultaneously.
  • RN Licensure
  • Minimum 1 year of managed care experience 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.

“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.”