Reviewer

• Conduct clinical reviews of behavioral health service requests, claims, and appeals
• Review pre-authorization requests, concurrent reviews, and retrospective behavioral health claims
• Apply InterQual and medical policy criteria to document medical necessity
• Refer cases not meeting criteria to the Psychiatric Medical Director for secondary review
• Support the appeals department in reviewing provider and member appeals within regulatory timelines
• Interact with behavioral health care providers regarding level-of-care and service decisions
• Document clinical decisions and rationale in the utilization management system
• Communicate determinations to providers and members by phone and written correspondence
• Analyze behavioral health member data to improve quality and appropriate service utilization
• Collaborate with Case Management, Quality, Provider Relations, and other internal departments
• Maintain compliance with CMS, NCQA, URAC, and other state, federal, and accreditation requirements
• Participate in audits, training, and quality-improvement initiatives
• Perform other job-related duties within the scope of responsibilities

Reviewer jobs in Louisiana

Behavioral Health Utilization Reviewer