Quality Clinical Reviewer

Magellan Health•Bethlehem, PA

1d•Remote

About The Position

This is a remote position in PA, must be licensed and reside in PA. Conducts reviews of clinical interactions and clinical documentation including reviews of case management records and provider treatment records. Collects data following established procedures and analyzes findings for purposes of continuous quality improvement and for internal and external reporting. Interacts with multiple stakeholders internally and externally. Provides clinical reviews of Quality of Care (QOC) and Critical/Adverse incidents related to clinical services. Audits and reviews case manager and provider clinical documentation and telephone interactions against regulations, accreditation standards and contract requirements. Reviews provider treatment records against clinical and procedural established standards. Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for care managers. Conducts reviews of Quality of Care and Critical/Adverse Incidents. Evaluates level of patient safety risk and need for follow-up actions per policies. Collects, analyzes and prepares clinical record information for projects related to assessing the efficiency, effectiveness and quality of the delivery of managed care services. Prepares monthly performance reports with assistance from Reporting and Analytics unit. Presents findings at provider and customer meetings as needed. Assists in the planning and implementation of activities to improve delivery of services and quality of care including the development and coordination of in-service education programs for providers and care managers. Responsible for auditing as well as validating internal audit results and/or corrective action plans. The job duties listed above are representative and not intended to be all-inclusive of what may be expected of an employee assigned to this job. A leader may assign additional or other duties which would align with the intent of this job, without revision to the job description.

Requirements

Bachelor's level clinician (RN) or master's level clinician (LCSW, LPC, LMHC, MFT) required.
5+ years of clinical experience required.
Will substitute 7 or more years of clinical experience along with an associate's degree and RN licensure in place of the bachelor's degree and RN licensure.
Experience working with total quality improvement or a behavioral healthcare background in treatment modalities, psychopharmacology, federal/state regulatory guidelines, performance measurement.
Ability to work independently with minimal supervision.
Project management skills and demonstrated experience.

Responsibilities

Conducts reviews of clinical interactions and clinical documentation including reviews of case management records and provider treatment records.
Collects data following established procedures and analyzes findings for purposes of continuous quality improvement and for internal and external reporting.
Interacts with multiple stakeholders internally and externally.
Provides clinical reviews of Quality of Care (QOC) and Critical/Adverse incidents related to clinical services.
Audits and reviews case manager and provider clinical documentation and telephone interactions against regulations, accreditation standards and contract requirements.
Reviews provider treatment records against clinical and procedural established standards.
Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for care managers.
Conducts reviews of Quality of Care and Critical/Adverse Incidents.
Evaluates level of patient safety risk and need for follow-up actions per policies.
Collects, analyzes and prepares clinical record information for projects related to assessing the efficiency, effectiveness and quality of the delivery of managed care services.
Prepares monthly performance reports with assistance from Reporting and Analytics unit.
Presents findings at provider and customer meetings as needed.
Assists in the planning and implementation of activities to improve delivery of services and quality of care including the development and coordination of in-service education programs for providers and care managers.
Responsible for auditing as well as validating internal audit results and/or corrective action plans.