Licensed Psychologist, Peer Reviewer - Remote (Tri-state Area)

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

The role of the Psychologist Peer Review involves applying clinical criteria and benefit plan requirements to Commercial, Medicaid, and Medicare cases, and making clinical and /or benefit determinations to continue coverage of treatment, shaping and modifying treatment as appropriate, or issuing an adverse benefit determination if applicable criteria is not met.  

If you are located in New York, New Jersey, or Connecticut, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Standard outpatient treatment, including requests for extended length sessions or single case agreements
• State-specific Medicaid services (e.g. Psychosocial Rehabilitation, Targeted Case Management, Home Based Habilitation, Supported Employment, etc.)
• Intensive Outpatient services for both Mental Health and Substance Abuse
• Participate in peer consultations, staff meetings, and trainings; entering determinations within federal, state, and local guideline requirements; and perform of other duties as required by the reviewer's manager
• Conduct Non-MD clinical reviews of the following type during a typical workday
• Requests for psychological or neuropsychological testing
• Review of outpatient treatment plans for services that are sent for Peer Review that do not appear to meet clinical criteria and/or when there are concerns about the quality of care
• Review of ongoing outpatient care in cases where the member's treatment episode exceeds normative standards
• Requests for non-standard outpatient services (extended-length visits, an in-network accommodation, intensive outpatient program with no MD involvement)
• Appeals of previously denied services or claims for outpatient non-MD services up to and including Intensive Outpatient Programming

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Licensed doctoral level (Ph.D. or Psy.D.) Psychologist
• License must be current, allow for full independent practice, and be unrestricted (you may be asked to obtain additional state licenses to meet growing business needs)
• 5+ years of post-licensure experience
• Experience completing peer reviews including psychological testing, other Children's services like CFTSS and HCBS and Mental Health and Substance Use Disorders
• Experience working with insurance agencies
• Experience working with children and adolescents
• Computer skills, including facility with Windows OS, Outlook, Word, and Excel
• Proven ability to type proficiently while speaking on the phone
• Permanent residence in the state of New York, New Jersey, or Connecticut

Preferred Qualifications:

• Experience working in a managed care setting
• Clinical experience with children in foster care or knowledge of NYS foster care system
• Experience with commercial, Medicaid and Medicare lines of business
• Experience with CPT and HCPC codes
• Clinical experience in higher levels of care (Intensive Outpatient)
• Clinical experience with children and adolescents
• Clinical experience with Substance Abuse diagnoses
• Clinical experience with Evidence-Based Treatment
• Advanced computer skills using Excel and Access Databases
• Demonstrated solid organizational and time management skills, with the ability to prioritize multiple demands within strict turn-around-time requirements
• Demonstrated solid written and verbal communication and negotiation skills