Job Description
Job Summary
As a Utilization Clinical Reviewer, you will use your expertise to assess medical records and ensure the appropriate use of psychiatric inpatient care. With your critical thinking and sound judgment, you'll evaluate the medical necessity of services, ensuring they meet established criteria. Your role will be key in supporting the Psychiatric Inpatient Concurrent Review process in line with regulatory standards such as NCQA, URAC, and the California Mental Health Services Authority (CAMHSA).
This is a full-time, remote opportunity. To be eligible, you must be a resident of California and hold an active clinical license in the state. While you won't have direct patient contact, you will make a significant impact on patient care through your work.
Key Responsibilities
Medical Record Review: Thoroughly review patient records to assess the medical necessity and appropriateness of care, ensuring that documentation complies with established standards.
Decision-Making: Approve services or refer cases to physician consultants as needed, providing clear and detailed rationales for any denials.
Data Documentation: Accurately document review-related data and submit all necessary administrative paperwork in a timely manner.
Process Improvement: Collaborate with stakeholders to identify opportunities to improve the review process and implement changes.
Collaboration and Communication: Serve as a liaison with internal and external stakeholders, fostering positive relationships and ensuring a seamless review process.
Professional Development: Participate in training and meetings to stay informed on updates and best practices in the review process.
Compliance and Confidentiality: Uphold medical record confidentiality in compliance with HIPAA and use secure systems for documentation.
Policy Adherence: Maintain professionalism in all communications and interactions, adhering to organizational communication standards.
Required Qualifications and Experience
Experience: At least 2 years of experience in managing or working with Medicaid, government health plans, or hospital programs.
Licensure: Active California licensure as an LCSW, LMFT, LPCC, or LCPC.
Education: Master's degree from an accredited program in social work, counseling, or a related field.
Clinical Expertise: In-depth understanding of psychiatric disorders, Level of Care determination, and mental health assessments.
Regulatory Knowledge: Familiarity with Parity in Mental Health and Substance Use Disorder Services, and public sector service systems.
Technical Proficiency: Proficiency in Microsoft Excel, Word, PowerPoint, Teams, and Outlook, as well as familiarity with web-based software and computer systems.
Analytical Skills: Ability to evaluate psychological, emotional, behavioral, and physical functioning, and offer evidence-based recommendations.
Attention to Detail: Strong organizational skills with the ability to manage tasks and deadlines efficiently.
Medicaid Knowledge: Experience navigating Medicaid programs or other government health systems.
Clinical Judgment: Proven ability to develop level-of-care recommendations based on medical records and evaluations.
Why This Role?
This is a fantastic opportunity to contribute meaningfully to the healthcare industry, with work that directly impacts individuals' lives. You'll be part of a supportive, collaborative team focused on improving health outcomes across the nation. We provide a work environment that encourages professional growth, offers flexible opportunities, and values the contributions of every team member.
Benefits
We offer a comprehensive benefits package designed to support both your professional life and personal well-being. Benefits include health plans, paid time off, retirement savings, wellness programs, educational assistance, corporate discounts, and more.
Compensation
The hourly compensation for this position ranges from $38.00 to $41.00.
Thank You for Your Interest!
We appreciate the time you've taken to apply for this role. Due to the volume of applicants, only those selected for further consideration will be contacted. We invite you to apply for future opportunities that may align with your skills and experience. Best of luck in your job search!
Equal Opportunity Employer Statement
We are an Equal Opportunity Employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by applicable law.
Employment Type: Full-Time
Salary: $ 38.00 41.00 Per Hour
Job Tags
Hourly pay, Full time, Flexible hours,