Job Summary
A company that provides critical health and human services programs to state, federal, and local governments is filling a position for a Remote Lead Quality Clinical Reviewer.
Individual must be able to fulfill the following responsibilities:
- Perform pre-admission and concurrent reviews for admissions and continued placement in Medicaid certified nursing facilities, utilizing federal and State’s criteria
- Review and communicate all information with providers, utilizing computer database system for determining nursing facility placement appropriateness
- Utilize both referral screens and medical records review to make determinations
Qualifications Include:
- Graduation from an accredited school of nursing, with current RN or LPN, or a MSW, or related license, in good standing, as dictated by the client contract
- At least five (5) years of experience working with individuals with a mental health diagnosis and/or intellectual disability, with the primary focus on behavioral health, as dictated by the client contract, plus two (2) years of quality review experience
- Minimum of two (2) years of medical experience with a strong understanding of rehabilitation potential, based on diagnosis, age, disease process and chronicity also as dictated by the client contract
- Experience or observed potential to supervise others in performing up to Reviewer 3 duties
- Ability to collect data, define problems, establish facts, and draw valid conclusions for supporting a superior written rationale for review determination
- Ability to develop and document a clinical rationale supporting the review decision as the final step in the review process
