Clinical Documentation Specialist
4 days ago
The Peer Review Specialist will play a vital role in our organization.
Our ideal candidate will be a licensed clinical or medical professional with extensive experience in behavioral health documentation and insurance requirements.
This specialist will support various levels of care by conducting peer reviews, case consultations, and interfacing with insurance payers to obtain continued authorization.
Key Responsibilities- Conduct thorough 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 from 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, such as ASAM, MCG, and InterQual.
- Accurately document all authorization and review interactions in the electronic medical record (EMR) system.
- 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.
- 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 highly desirable.
- 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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