- Audits and reviews case manager and provider clinical documentation and telephone interactions against regulations, accreditation standards and contract requirements.
- Reviews provider treatment records against clinical and procedural established standards.
- Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for care managers.
- Conducts reviews of Quality of Care and Critical/Adverse Incidents.
- Evaluates level of patient safety risk and need for follow-up actions per policies.
- Collects, analyzes and prepares clinical record information for projects related to assessing the efficiency, effectiveness and quality of the delivery of managed care services.
- Prepares monthly performance reports with assistance from Reporting and Analytics unit. Presents findings at provider and customer meetings as needed.
- Assists in the planning and implementation of activities to improve delivery of services and quality of care including the development and coordination of in-service education programs for providers and care managers.
- Responsible for auditing as well as validating internal audit results and/or corrective action plans.
Other Job Requirements
Responsibilities
Bachelor’s level clinician (RN) or master’s level clinician (LCSW, LPC, LMHC, MFT) required.
5+ years of clinical experience required.
Will substitute 7 or more years of clinical experience along with an associate’s degree and RN licensure in place of the bachelor’s degree and RN licensure.
Experience working with total quality improvement or a behavioral healthcare background in treatment modalities, psychopharmacology, federal/state regulatory guidelines, performance measurement.
Ability to work independently with minimal supervision.
Project management skills and demonstrated experience.
General Job Information
Title
Quality Clinical Reviewer – Remote
Grade
25
Work Experience – Required
Clinical
Work Experience – Preferred
Quality
Education – Required
A Combination of Education and Work Experience May Be Considered. – Nursing, Bachelor’s – Nursing, Master’s – Behavioral Health
Education – Preferred
PsyD – Clinical Psychology
License and Certifications – Required
LCSW – Licensed Clinical Social Worker – Care Mgmt, LMHC – Licensed Mental Health Counselor – Care Mgmt, LPC – Licensed Professional Counselor – Care Mgmt, MFT – Marriage and Family Therapist – Care Mgmt, PSY – Psychologist – Care Mgmt, RN – Registered Nurse, State and/or Compact State Licensure – Care Mgmt
License and Certifications – Preferred
Salary Range
Salary Minimum:
$64,285
Salary Maximum:
$102,855
This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual’s skills, experience, education, and other job-related factors permitted by law.
This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing.
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.