Licensed Clinical Review Clinician
Job Summary
Performing clinical reviews to resolve and process appeals, the full-time Licensed Clinical Review Clinician will work remotely to assess medical necessity for services by reviewing medical records and clinical data in accordance with policies 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 compliance with State, Federal, and NCQA standards
- Communicates with members, providers, and other departments regarding appeal requests and resolutions
Required qualifications
- Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
- 2 - 4 years of related experience in clinical review or appeals processes
- State Licensure as an RN, LPN, LVN, or relevant clinical license (e.g., LCSW, LMHC, LPC, LMFT, Licensed Psychologist)
- Knowledge of NCQA, Medicare, and Medicaid regulations preferred
- Familiarity with utilization management processes preferred
Complete Job Description
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