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Initial Clinical Reviewer II (RN)

Company: Magellan Health
Location: Phoenix
Posted on: May 18, 2018

Job Description:

Initial Clinical Reviewer II (RN) (ICR II = RN) Functions in a clinical review capacity to evaluate all cases, which do not pass the authorization approval process at first call while promoting a supportive team approach with call center staff. Initial clinical reviewers are supported by Physician clinical review staff (MDs) in the utilization management determination process. ESSENTIAL FUNCTIONS: Reviews charts and analyzes clinical record documentation in order to approve services that meet clinical review criteria. Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for other clinical staff. Conducts regular audits, as assigned, to ensure guidelines are applied appropriately. In states where required, refers all cases that an approval cannot be rendered to the Physician Clinical Reviewer. In States where allowed, will make denial determinations as a specific case warrants. Converses with medical office staff in order to obtain additional pertinent clinical history/information; notifies of approvals and denials, giving clinical rationale. Provides optimum customer service through professional/accurate communication while maintaining NCQA and health plan?s required timeframes. Documents all communication with medical office staff and/or treating provider. Practices and maintains the principles of utilization management by adhering to policies and procedures. Participates in on-going training programs to ensure quality performance in compliance with applicable standards and regulations. General Job Information Title Initial Clinical Reviewer II (RN) Grade 24 Job Family Care Management Country United States of America FLSA Status United States of America (Non-Exempt) Recruiting Start Date 4/23/2018 Date Requisition Created 4/23/2018 Minimum Qualifications Education Associates: Nursing (Required), Bachelors License and Certifications - Required ASRT - American Society of Radiologic Technologists Certification - Radiology, OT - Occupational Therapist - Care Mgmt, PT - Physical Therapist, State Licensure - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt License and Certifications - Preferred Other Job Requirements Responsibilities Minimum 1 year of managed care experience. For physical health roles, 2-5 years of either physical therapy, occupational therapy or speech language therapy experience preferred., Strong interpersonal and communication skills. Basic computer skills; must be able to talk and type simultaneously. Competencies Language(s) Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled BACH_a33d1a

Keywords: Magellan Health, Phoenix, Initial Clinical Reviewer II (RN), Healthcare, Phoenix, Arizona

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