Clinical Reviewer II - Licensed /Remote in NM

Gathers and synthesizes clinical information in order to authorize services. Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity criteria. Collects and analyzes utilization information. Assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity. Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria.

• Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria.
• Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network.
• As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms.
• Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and policies, procedures and criteria.
• Develops and manages new enrollee transitions and those involving a change in provider relationships.
• Develops and implements transition plans, as indicated, to ensure continuity of care.
• Negotiates and documents single case agreements according to procedures.
• In conjunction with providers and facilities, identifies, develops and monitors discharge plans.
• Collaborates with the Care Coordination team to implement support for transitions in care.
• Facilitates timely sharing of enrollees' clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care.
• Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases.
• Assures that case documentation for each decision is complete, including related correspondence.
• Participates in Care Coordination team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.
• Maintains an active work load in accordance with performance standards. 
• Works with community agencies as appropriate. 
• Participates in network development including identification and recruitment of quality providers as needed. 
• Advocates for the enrollee to ensure health care needs are met. 
• Interacts with providers in a professional, respectful manner.
• Provides coverage of Nurse Line and/or Crisis Line as requested or required for position.

Other Job Requirements

Responsibilities

RN or clinical credentials in a behavioral health field. If not an RN, must hold master's or doctoral Degree. If nurse, RN license at a minimum. If other than RN, master's level licensed behavioral health professional.
Good organization, time management and verbal and written communication skills.
Knowledge of utilization management procedures, Medicaid benefits, community resources and providers.
knowledge and experience in diverse patient care settings including inpatient care.
Ability to function independently and as a team member.
Knowledge of ICD and DSM IV coding or most current edition.
Ability to analyze specific utilization problems and creatively plan and implement solutions.
Ability to use computer systems.
5 or more years of experience post degree in a clinical, psychiatric and/or substance abuse health care setting. 
Also requires minimum of 2 years of experience conducting utilization management according to medical necessity criteria.

General Job Information

Title

Clinical Reviewer II - Licensed /Remote in NM

Grade

25

Work Experience - Required

Clinical, Utilization Management

Work Experience - Preferred

Education - Required

Associate - Nursing, Master's - Behavioral Health

Education - Preferred

License and Certifications - Required

LCSW - Licensed Clinical Social Worker - Care Mgmt, LPC - Licensed Professional Counselor - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt

License and Certifications - Preferred

Salary Range

Salary Minimum:

$64,285

Salary Maximum:

$102,855

This information reflects the anticipated b