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Clinical Reviewer - Remote Position

Company: Kepro
Location: Seattle
Posted on: May 14, 2022

Job Description:


Clinical Reviewer - Remote Position

  • Are you an experienced Clinical Reviewer looking for a new challenge?
  • Do you value care management and quality improvement?
  • Are you motivated, energetic, and excited to become part of the Kepro team?
    If so, you might be our next new team member!
    • This is a fully remote position**
      Who We Need

      Clinical Reviewers utilize their expertise to determine medical necessity by reviewing medical records and comparing against appropriate criteria, benefit plan, and contract requirements. Reviewers use critical thinking and decision-making skills to determine medical appropriateness of psychiatric or substance abuse inpatient level of care, as well as various outpatient therapies and services. In this role you will support overall consistency, thoroughness, and accuracy of the review process, while maintaining production goals and Quality Assurance (QA) standards. You will also ensure that day-to-day processes are conducted in accordance with URAC and other regulatory standards.

      Why us?

      Kepro is a rapidly growing national quality improvement and care management organization. We work to ensure that over 20 million people receive the right care, at the right time, in the right setting.

      People Focused. Mission Driven.

      Shape the future of healthcare with us. We are mission driven to improve lives through healthcare quality and clinical expertise.

      We do this through our people.

      At Kepro, you can do meaningful work that makes a real difference for the lives of individuals across the country. We are an organization that cares deeply about our employees and we provide the training and support to do the best work of your career.

      Benefits are a key component of your rewards package at Kepro. These benefits are designed to provide you and your family additional protection, security, and support for both your career and your life away from work. They are comprehensive and fit a variety of needs and situations. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts and more.

      What You'll Do
      • 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.
      • Performs ongoing reassessment of review process to offer opportunities for improvement and/or change.
      • Fosters positive and professional relationships and acts as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process.
      • Always maintains medical records confidentiality 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 KEPRO to provide a flexible workforce to meet client/consumer needs.
      • Other duties as assigned
      • 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.
        The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.

        What You'll Need

        Required Qualifications
        • BCBA, LCSW, LCPC, LPCC, LMFT with active license is required
          Knowledge, Skills, Abilities
          • Knowledge of utilization management program and processes with relevant experience.
          • Knowledge of psychiatric and substance use disorders
          • Knowledge of standards of practice related to mental health and other disorders typically requiring psychiatric inpatient.
          • Develops level of care recommendations based upon clinical evaluations.
          • Assesses and analyzes psychological, emotional, behavioral and physical functioning.
          • Ability to attend to detail, effectively prioritize and execute tasks in a timely manner.
          • Ability to communicate effectively to individuals and groups through spoken, written and electronic media.
          • Ability to interact with healthcare professionals, patients, their families and other supports.
          • Ability to interact with various office staff as needed to support necessary workflows.
          • Ability to utilize computer equipment and web-based software to conduct work.
          • Ability to determine a clinical diagnosis accounting for psychological, substance use and behavioral issues.
          • Computer proficiency in Microsoft Excel, Word, PowerPoint, Teams, and Outlook.
          • Knowledge of Parity in Mental Health and Substance Use Disorder Services Final Rule (Parity Rule; Title 42 of the CFR, part 438.910)
          • Knowledge of standards of practice related to determination of Level of Care.
          • Knowledge of InterQual criteria
            • Minimum 3 years direct behavioral/mental health experience in a clinical setting required
            • Minimum of 1 year utilization review experience in a health plan environment required
            • Working knowledge of InterQual criteria application strongly preferred
            • Experience with commercial health plans preferred.
              Thank You!

              We know your time is valuable and we thank you in advance for applying for this position. Due to the high volume of applicants we receive, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Kepro and invite you to apply to future openings that may be of interest. Best of luck in your search!

              - The Kepro Talent Acquisition Team

              Mental And Physical Requirements

              The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.

              EOE AA M/F/Vet/Disability

              Kepro is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Keywords: Kepro, Seattle , Clinical Reviewer - Remote Position, Healthcare , Seattle, Washington

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