Licensed Clinical Review Clinician
Job Summary
To resolve and process appeals, the full-time Licensed Clinical Review Clinician will perform clinical reviews of medical records and clinical data remotely, ensuring compliance with policies and NCQA standards, while participating in weekend on-call rotations and holiday coverage.
Key responsibilities
- Prepares case reviews for Medical Directors by researching appeals and analyzing applicable criteria
- Ensures timely review and response to appeals in accordance with State, Federal, and NCQA standards
- Communicates with members, providers, and facilities regarding appeal requests and generates resolution communications
Required qualifications
- Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
- 2 - 4 years of related experience
- Fully licensed as LPN, LVN, RN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist
- Knowledge of NCQA, Medicare, and Medicaid regulations preferred
- Experience in utilization management processes preferred
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