Texas Licensed Clinical Review Clinician

Job Summary

To support the Medical Management/Health Services team, the full-time Texas Licensed Clinical Review Clinician will perform clinical reviews to resolve and process appeals, ensuring compliance with policies and guidelines while working remotely.

Key responsibilities

• Prepares case reviews for Medical Directors by researching appeals and analyzing applicable criteria
• Ensures timely processing and response to appeals in accordance with State, Federal, and NCQA standards
• Communicates with members, providers, and other departments regarding appeals 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 in clinical review or appeals
• Knowledge of NCQA, Medicare, and Medicaid regulations preferred
• State Licensure as an RN, LPN, LVN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist required
• Familiarity with utilization management processes preferred