Licensed Clinical Review Clinician

Job Summary

Performing clinical reviews to resolve and process appeals, the full-time Licensed Clinical Review Clinician will review medical records and clinical data to determine medical necessity for services while working remotely and adhering to State, Federal, and NCQA standards.

Key responsibilities

• Prepares case reviews for Medical Directors by researching appeals and analyzing applicable criteria
• Ensures timely review and processing of appeals in accordance with regulatory standards
• Communicates with members, providers, and other departments regarding appeals requests

Required qualifications

• Graduate from an accredited School of Nursing or a Master's degree in a related field with 2-4 years of experience
• Active state licensure as an LPN, LVN, RN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist
• Experience managing Behavioral Health caseloads or direct Psychiatric Nursing preferred
• Familiarity with NCQA, Medicare, and Medicaid regulations preferred
• Proficient in Microsoft Office applications and digital communication tools