- Reviews charts and analyzes clinical record documentation.
- Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for other clinical staff.
- 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.
- 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 other clinical staff.
- Provides training, interpretation and support for QI Clinical Reviewer staff.
- Audits and validates internal audit results and/or corrective action plans.
Other Job Requirements
Responsibilities
RN/BSN or clinical credentials in a behavioral health field. If not an RN, must hold Masters or Doctoral Degree and be a licensed behavioral health professional.
Good organization, time management and verbal and written communication skills.
Knowledge of utilization management procedures, Medicaid benefits, community resources and providers.
knowledge and experience in diverse patient care settings including inpatient care.
Ability to function independently and as a team member.
Knowledge of ICD and DSM IV coding or most current edition.
Ability to analyze specific utilization problems and creatively plan and implement solutions.
Ability to use computer systems.
7 or more years of experience post degree in a clinical, psychiatric and/or substance abuse health care setting.
Also requires minimum of 4 years of experience conducting utilization management according to medical necessity criteria.
General Job Information
Title
Clinical Reviewer III (Baton Rouge, LA or Remote in LA)
Grade
26
Work Experience – Required
Clinical, Utilization Management
Work Experience – Preferred
Education – Required
Bachelor’s – Nursing, Master’s – Social Work
Education – Preferred
License and Certifications – Required
LCSW – Licensed Clinical Social Worker – Care Mgmt, LISW – Licensed Independent Social Worker – Care Mgmt, LMFT – Licensed Marital and Family Therapist – Care Mgmt, LMSW – Licensed Master Social Worker – Care Mgmt, LPCC – Licensed Professional Clinical Counselor – Care Mgmt, RN – Registered Nurse, State and/or Compact State Licensure – Care Mgmt
License and Certifications – Preferred
Salary Range
Salary Minimum:
$70,715
Salary Maximum:
$113,145
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.