Initial Clinical Reviewer - RN
Missouri, United States Minor Outlying Islands
Job DescriptionFunctions 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 - RN
Job FamilyClinical Services Group
CountryUnited States of America
FLSA StatusUnited States of America (Non-Exempt)
Recruiting Start Date2/10/2020
Date Requisition Created2/10/2020
EducationAssociates: Nursing (Required), Bachelors: Nursing
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, ST - Speech Therapist, State Licensure - Care Mgmt
License and Certifications - Preferred
Other Job Requirements
Must possess excellent interpersonal and communication skills, basic computer skills; must be able to talk and type simultaneously
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.
At least 1 year of managed care experience
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.”