Peer Review Specialist

2 weeks ago

Calamba, Philippines Remote Raven Full time

Overview

Position Summary

We are seeking a highly skilled and detail-oriented Peer Review Specialist to support our Residential, PHP, and IOP levels of care. This individual will be responsible for conducting peer reviews, case consultations, and interfacing with insurance payers to obtain continued authorization. The ideal candidate will be a licensed clinical or medical professional who is deeply familiar with behavioral health documentation and insurance requirements.

Key Responsibilities
  • Conduct peer reviews and clinical case consultations with insurance payers to secure continued stay authorizations.
  • Review comprehensive client charts prior to peer reviews, including:
    • Progress notes (individual, group, family sessions)
    • Psychiatric evaluations
    • History and physical exams (H&P)
    • Nursing assessments and daily logs
    • Medical vitals, height, weight, and lab reports
  • Collaborate with clinical and medical team members to gather updated and relevant information that supports the client\'s medical necessity for continued care.
  • Maintain a working knowledge of insurance medical necessity criteria (e.g., ASAM, MCG, InterQual).
  • Accurately document all authorization and review interactions in the EMR or designated systems.
  • Participate in interdisciplinary team meetings and provide feedback regarding documentation practices that support utilization review.
  • Proactively track authorization timelines, expirations, and upcoming reviews to avoid service interruptions.
  • Ensure adherence to HIPAA, ethical standards, and all payer requirements during reviews and documentation.
Required Qualifications
  • Minimum: Licensed Registered Nurse (RN)
  • Preferred: Nurse Practitioner (NP), Medical Doctor (MD/DO), Licensed Therapist (LCSW, LPC, LMFT, PsyD, PhD)
  • Minimum of 2 years\' experience in behavioral health, substance use, or psychiatric care.
  • Prior experience with utilization review, case management, or insurance authorization processes strongly preferred.
  • Familiarity with insurance platforms and payer-specific guidelines.
  • Excellent communication skills with the ability to represent clinical information clearly and persuasively.
  • Strong attention to detail and ability to work independently and under pressure.
Requirements
  • This is a full time job
  • 100% Remote
  • $10-$11/hr
Details
  • Seniority level: Mid-Senior level
  • Employment type: Full-time
  • Job function: Administrative
  • Industry: Hospitals and Health Care

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