Behavioral Health Clinical Reviewer

Behavioral Health Clinical Reviewer

The Behavioral Health Clinical Reviewer is responsible for evaluating clinical records and referral documentation to determine eligibility and fit for Nexus behavioral health and neurodevelopmental programs. This role involves preparing high-quality clinical evaluations and summaries that meet payer requirements, including insurance and Medicaid standards. The reviewer ensures admissions decisions are made efficiently, accurately, and in compliance with regulatory, clinical, and Nexus program guidelines.

Key Responsibilities

Referral & Record Review

• Review incoming referral packets, medical and clinical histories, assessments, and related documentation.
• Determine program appropriateness for behavioral health, autism, intellectual/developmental disabilities, and medically complex cases.

Funder & Payer Compliance

• Maintain up-to-date knowledge of insurance and Medicaid documentation standards.
• Draft clinical documentation that addresses payer expectations and anticipates potential questions or objections.

Collaboration & Communication

• Partner with referral sources, families, and internal teams to clarify information and obtain missing documentation.
• Clearly communicate admission decisions and next steps.

Timeliness & Quality

• Process referrals and evaluations promptly while maintaining clinical accuracy and compliance.
• Balance efficiency with quality, ethics, and thoroughness.

Continuous Learning & Improvement

• Stay current on behavioral health conditions, neurodevelopmental disorders, and medical complexities.
• Monitor evolving payer policies, assessment tools, and evidence-based practices.

Qualifications

Education

• Master's degree in Social Work, Clinical Psychology, Counseling, Applied Behavior Analysis, or a related behavioral health field; or Bachelor's degree in Nursing.
• Doctoral degree (PhD, PsyD, DSW) preferred but not required.

Experience

• Minimum 3 years of clinical experience in behavioral health, developmental disabilities, or autism spectrum disorders.
• Proven experience writing clinical assessments/evaluations for payer or insurance approval.
• Familiarity with private insurance and Medicaid authorization processes.
• Experience collaborating with interdisciplinary clinical teams.

Licensure/Certification

• Active clinical license (e.g., LCSW, LPC, LMFT, BCBA, RN, Psychologist) OR eligibility to obtain licensure in Texas.

Skills & Attributes

• Exceptional written communication skills, with ability to draft clear, concise, and persuasive clinical narratives.
• Strong interpersonal skills with the ability to work compassionately with families, clinicians, and referral partners.
• High attention to detail and strong critical thinking.
• Ability to prioritize, multi-task, and meet deadlines in a fast-paced setting.
• Proficiency with EMR and CRM systems.