State Licensed Clinical Review Clinician

Job Summary

To support the appeals process in behavioral health, the full-time State Licensed Clinical Review Clinician will perform clinical reviews, analyze medical records, and ensure compliance with relevant standards while working remotely.

Key responsibilities

• Perform clinical reviews and prepare case reviews for Medical Directors regarding appeals
• Ensure timely processing and communication of appeals in accordance with State, Federal, and NCQA standards
• Collaborate with interdepartmental teams to enhance clinical appeals processes and prevent recurrences

Required qualifications

• Graduate from an Accredited School of Nursing or a Master's degree in a related Behavioral/Counseling field with 2-4 years of relevant experience
• Active RN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist certification required
• Preferred 6+ years of experience in Behavioral Health settings managing member caseloads
• Knowledge of NCQA, Medicare, and Medicaid regulations preferred
• Experience with clinical data and the appeals process preferred