Required Skills:

• Minimum 3 years' experience in a related clinical setting.


• Managed Care and Utilization Management experience required.


• Behavioral Health Management experience required.


• Registered Nurse graduate from an accredited institution with an Associate Degree or Bachelor's Degree.

Skills:

• Managed Care


• Medical Management


• Outpatient


• Registered Nurse

Minimum Degree Required:

• Associate's Degree (Community College, MBO)

Certifications & Licenses:

• Registered Nurse

• Duties:


• Under the direction of the Supervisor, the Clinical Care Reviewer (CCR) is responsible for completing medical necessity reviews.


• Using clinical knowledge and experience, the clinician reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review.


• It is within the Clinical Care Reviewer's discretion to retain requests for additional information and/or request clarification.


• The CCR will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases to integrated care management as needed.


• The CCR will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when indicated.


• CCRs are responsible to ensure that treatment delivered is appropriately utilized and meets the Member's needs in the least restrictive, least intrusive manner possible.


• The CCR will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit's business and uses clinical judgment in their application.