Clinical Review Specialist

1 day ago

Mandaue City, Central Visayas, Philippines beBeeReview Full time $42,960 - $46,130
Job Opportunity

We are seeking a detail-oriented professional to fill the position of Clinical Review Specialist.

This role requires conducting thorough reviews, case consultations, and interacting with insurance payers to secure continued authorization. The ideal candidate will be a licensed clinical or medical professional well-versed in behavioral health documentation and insurance requirements.

Key Responsibilities:
  • Conduct comprehensive reviews and case consultations with insurance payers to obtain continued stay authorizations.
  • Analyze client charts prior to 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 information that supports the client's medical necessity for continued care.
  • Maintain knowledge of insurance medical necessity criteria (e.g., ASAM, MCG, InterQual).
  • Diligently document all interactions in electronic medical records or designated systems.
  • Participate in interdisciplinary team meetings and provide feedback on documentation practices that support utilization review.
  • Proactively track authorization timelines and expirations to avoid service interruptions.
Required Qualifications:
  • Licensed Registered Nurse (RN) minimum requirement.
  • Prior experience in behavioral health, substance use, or psychiatric care is essential.
  • Strong communication skills with the ability to clearly present clinical information.
  • Familiarity with insurance platforms and payer-specific guidelines is required.
Benefits and Details:
  • Full-time remote opportunity.
  • Senior-level position.
  • Administrative job function within the healthcare industry.

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