Job Description
Job Summary
As a Utilization Clinical Reviewer, you will play an essential role in evaluating medical records to ensure the medical necessity of psychiatric inpatient care. By applying your clinical expertise, you'll assess whether services align with established guidelines, ensuring that individuals receive appropriate care. This position is crucial in maintaining the integrity of the Psychiatric Inpatient Concurrent Review process and follows regulatory standards such as those set by NCQA, URAC, and the California Mental Health Services Authority (CAMHSA).
This is a full-time, remote position open to residents of California with active licensure. It's an exciting opportunity to make a meaningful impact on healthcare without direct patient interaction.
Key Responsibilities
Medical Record Review: Review patient records to determine the medical necessity of care, ensuring documentation meets service requirements.
Decision-Making: Approve services or refer cases to physician consultants, providing clear and detailed rationales for any denials.
Data Documentation: Accurately document review-related data and submit necessary administrative paperwork in a timely manner.
Process Improvement: Identify opportunities to enhance review processes and collaborate with team members and stakeholders to implement improvements.
Collaboration and Communication: Serve as a liaison between internal and external stakeholders, building positive relationships and ensuring smooth communication throughout the review process.
Professional Development: Engage in ongoing training and meetings to stay current on updates relevant to the review process.
Compliance and Confidentiality: Uphold patient confidentiality by adhering to HIPAA policies and utilizing secure systems for data management.
Policy Adherence: Maintain professionalism and adhere to communication standards in all verbal and written interactions.
This is not an exhaustive list, and additional duties may be assigned as needed.
Required Qualifications and Experience
Experience: At least 2 years of experience 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, as well as public sector service systems.
Technical Proficiency: Comfortable using Microsoft Office tools (Excel, Word, PowerPoint, Teams, Outlook) and web-based software.
Analytical Skills: Ability to evaluate psychological, emotional, behavioral, and physical functioning and provide evidence-based recommendations.
Detail-Oriented: Strong organizational skills, with the ability to prioritize and meet deadlines.
Medicaid Knowledge: Experience with Medicaid programs or similar government health systems.
Clinical Record Review: Ability to develop level-of-care recommendations based on clinical medical records and evaluations.
Why You Should Join Us
You'll be part of a dynamic team of healthcare professionals, where your work will directly impact lives across the country. We're committed to your growth and success, providing you with the resources, training, and support you need to thrive. If you're looking for meaningful work that makes a real difference in the lives of others, this is the place for you.
Our Commitment to You
We value your time and appreciate your interest in this position. Due to the high volume of applications, only those selected for further consideration will be contacted. We encourage you to apply for future opportunities that align with your skills and career goals.
Equal Opportunity Employer
We are an equal opportunity employer and value diversity in our workforce. We consider all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.
Benefits
We offer a comprehensive benefits package designed to support your health, well-being, and career. Our benefits include health plans, paid time off, retirement savings, wellness programs, educational assistance, corporate discounts, and more.
Compensation
The hourly compensation for this role ranges from $38.00 to $41.00.
Employment Type: Full-Time
Salary: $ 38.00 41.00 Per Hour
Job Tags
Hourly pay, Full time, Remote job,