- 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.
- Minimum of 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.
- Master’s Degree preferred
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