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 escalate 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.