Job Description

Job Description

Job Description

Behavioral Health Clinical Reviewer

The Clinical Reviewer will use clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking, and decision-making skills to determine medical appropriateness while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA, URAC, and other regulatory standards.

Responsibilities:

• Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care; determine if the medical record documentation supports the need for services.
• Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring the reason for the denial is described in sufficient detail in correspondence.
• Abstracts review related data/information accurately and timely on appropriate review tool by the appropriate means. Accurate and timely submission of all administrative and review related documents to appropriate parties.
• Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building in order to facilitate the review process.
• Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
• Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, and adherence to HIPAA policies.
• Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following Client policies, procedures, and guidelines.
• Actively cross-trains to perform the duties of others within the Client network to provide a flexible workforce to meet client/consumer needs.
  
   

Requirements:

• Active unrestricted license in Virginia: Psychiatric/Mental Health RN, Licensed Clinical Social Worker (LCSW), Licensed Mental Health Professional (LMHP), or Licensed Marriage and Family Therapist (LMFT), 
• Knowledge of InterQual or ASAM criteria
• Knowledge of current NCQA/URAC standards
• 2+ years of Utilization Review and/or Prior Authorization experience
• 3+ years of direct experience in a clinical setting or other applicable State Clinical experience.
• Experience in Community Mental Health, Crisis Mental Health, Residential Services, or Inpatient Behavioral health/Psychology

Required Skills:

• Excellent verbal and written communication skills
• Ability to problem solve.
• Proficient computer skills, including Microsoft Office.
• Ability to provide technical consultation and policy interpretation.
• Excellent customer services

 

Proper email communication will only be done to and from @ astyra.com email addresses. Please ensure you are communicating with approved Astyra recruiters by checking this point when receiving offers and messages from us. Please ensure you are communicating within these guidelines and proper channels for the quickest possible interview consideration!

#AC

Job Tags

Contract work, Flexible hours,

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