Clinical Care Specialist

2 days ago

Mandaluyong City, National Capital Region, Philippines beBeePeer Full time $40,000 - $44,000
Role Overview

This role involves conducting peer reviews, case consultations, and interfacing with insurance payers to obtain continued authorization for residential, PHP, and IOP levels of care.

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, psychiatric evaluations, history and physical exams, nursing assessments, medical vitals, 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, such as ASAM and MCG.
  • Accurately document all authorization and review interactions in electronic medical records 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 and ethical standards during reviews and documentation.
Required Skills and 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 is 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.

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