School of Social Work

CLINICAL REVIEWER

• Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care; determines if the medical record documentation supports the need for services.
• Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail on correspondence.
• Abstracts review related data/information accurately and timely on appropriate review tool by the appropriate means. Accurate and timely submission of all administrative and review related documents to appropriate parties.
• Performs ongoing reassessment of review process to offer opportunities for improvement and/or change.
• Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building in order to facilitate the review process.
• Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
• Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices.
• Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following KEPRO policies, procedures and guidelines
• Actively cross-trains to perform duties of other contracts within the KEPRO network to provide a flexible workforce to meet client/consumer needs.
• Active unrestricted LCSW or LCPC only.

• Knowledge of current NCQA/URAC standards strongly preferred
• Medical record abstracting skills required.
• Knowledge of the organization of medical records, medical terminology, and disease process required.
• Strong clinical assessment and critical thinking skills required.
• Excellent verbal and written communication skills required.
• Ability to work in a team environment.
• Flexibility and strong organizational skills needed.
• Must be proficient in Microsoft Office and internet/web navigation

• Minimum of one year UR and/or Prior Authorization or related experience.
• For BH Programs: Minimum 3 years direct behavioral/mental health experience in a clinical setting or other applicable State and/or Compact State clinical experience or license per contract requirements.