Clinical Reviewer

Overview Perform utilization management functions to ensure correct application of contract and policy benefits for assigned lines of business. Work independently under limited supervision, handling moderately complex projects and assignments with occasional guidance. Make clinical decisions using approved and accepted plan policies and criteria. Determine eligibility and benefit coverage according to member and provider contracts. Respond to authorization requests for medications, inpatient procedures, and services. Document and report potential quality of care or service issues to leadership. Provide review according to established criteria for procedural authorization. Collaborate with entry-level professionals and support employees, offering guidance and assistance. Key Responsibilities & Duties Conduct utilization management reviews for behavioral health services to ensure compliance with policies and contracts. Evaluate eligibility and benefits coverage for members and providers, ensuring accuracy and adherence to guidelines. Respond promptly to authorization requests for medications, procedures, and services, providing clear and accurate decisions. Document findings and escal… potential quality of care issues to appropriate leadership for resolution. Utilize clinical expertise to make informed decisions based on established criteria and policies. Collaborate with team members to ensure consistency and quality in utilization management practices. Assist entry-level professionals and support staff with guidance and expertise in clinical decision-making. Participate in ongoing training and development to stay updated on industry standards and practices. Job Requirements Bachelor of Science in Nursing (BSN) or equivalent educational background. Minimum of 3 years of relevant behavioral health utilization management experience. Valid unrestricted Idaho Registered Nursing License or Social Worker License. Strong understanding of clinical decision‑making processes and utilization management criteria. Proven ability to work independently under limited supervision on moderately complex assignments. Excellent documentation skills and ability to report quality of care issues effectively. Experience providing guidance and assistance to entry-level professionals and support employees. Familiarity with procedural authorization review processes and established criteria. #J-18808-Ljbffr Greenkey Resources LLC