New York Licensed Clinical Reviewer

Job Summary

Performing clinical reviews to resolve and process appeals, the full-time New York Licensed Clinical Reviewer will analyze medical records and clinical data to determine medical necessity for services while working remotely.

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 State, Federal, and NCQA standards
• Communicates with members, providers, and facilities regarding appeals requests and generates appropriate resolution communications

Required qualifications

• Active, unrestricted New York State RN license or equivalent licensure (LCSW, LMHC, LPC, LMFT, or Licensed Psychologist)
• Bachelor's degree in Nursing or a Master's degree in Behavioral Health or Social Work
• 2+ years of experience in acute care, utilization management, or appeals
• Knowledge of MCG/InterQual criteria and NYS Medicaid, Medicare, and Marketplace appeal regulations
• Utilization management certification (CCM) preferred