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Behavioral Health Quality Clinical Reviewer - Remote California

Company: Magellan Health
Location: San Diego
Posted on: July 1, 2020

Job Description:

Candidates must hold one of the following active licenses in the state of California: RN, LCSW, LPCC, LMFT

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.

    General Job Information

    TitleBehavioral Health Quality Clinical Reviewer - Remote CaliforniaGrade24Job FamilyQuality GroupCountryUnited States of AmericaFLSA StatusUnited States of America (Exempt)Recruiting Start Date5/4/2020Date Requisition Created5/4/2020Work ExperienceClinicalEducationA Combination of Education and Work Experience May Be Considered.: Nursing (Required), Bachelors: Nursing (Required), Masters: Behavioral Health (Required)License and Certifications - RequiredLCSW - Licensed Clinical Social Worker - Care Mgmt, LMHC - Licensed Mental Health Counselor - Care Mgmt, LPC - Licensed Professional Counselor - Care Mgmt, MFT - Marriage and Family Therapist - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care MgmtLicense and Certifications - Preferred

    Other Job Requirements

    Responsibilities

    • Bachelors level clinician (RN) or Masters level clinician (LCSW, LPC, LMHC, MFT) required.
    • Will substitute 5 or more years of clinical experience along with an Associates degree and RN licensure in place of the Bachelors 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
    • Licensed clinician with 5 years of healthcare quality improvement experience.


      • Managed health care experience preferred.
      • National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC) accreditation standards and processes experience preferred.

        Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.

Keywords: Magellan Health, San Diego , Behavioral Health Quality Clinical Reviewer - Remote California, Healthcare , San Diego, California

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