15 days old

Initial Clinical Reviewer - RN - IPM/MSK

Magellan Health
Maryland Heights, MO 63043
  • Job Code
  • Jobs Rated
Functions in a clinical review capacity to evaluate all cases, which do not pass the authorization approval process at first call while promoting a supportive team approach with call center staff. Initial clinical reviewers are supported by Physician clinical review staff (MDs) in the utilization management determination process.
  • Reviews charts and analyzes clinical record documentation in order to approve services that meet clinical review criteria.
  • Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for other clinical staff.
  • Conducts regular audits, as assigned, to ensure guidelines are applied appropriately.
  • In states where required, refers all cases that an approval cannot be rendered to the Physician Clinical Reviewer. In States where allowed, will make denial determinations as a specific case warrants.
  • Converses with medical office staff in order to obtain additional pertinent clinical history/information; notifies of approvals and denials, giving clinical rationale.
  • Provides optimum customer service through professional/accurate communication while maintaining NCQA and health plan's required timeframes.
  • Documents all communication with medical office staff and/or treating provider.
  • Practices and maintains the principles of utilization management by adhering to policies and procedures.
  • Participates in on-going training programs to ensure quality performance in compliance with applicable standards and regulations.

Other Job Requirements


  • Must have current licensure as a RN,
  • RN licensure required and additional State specific licensure may be an required depending on the contract/business need.
  • Licensure is required for this position, specifically a current license that meets State, Commonwealth or customer -specific requirements.
  • Strong interpersonal and communication skills.
  • Basic computer skills; must be able to talk and type simultaneously.

One year of managed care experience and preferred 5+ years of clinical experience.

General Job Information

Work Experience

Associates: Nursing (Required), Bachelors (Required)

License and Certifications - Required
ASRT - American Society of Radiologic Technologists Certification - Radiology, OT - Occupational Therapist, State Licensure - Care Mgmt, PT - Physical Therapist, State Licensure - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt, ST - Speech Therapist, State Licensure - Care Mgmt

License and Certifications - Preferred

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.

Jobs Rated Reports for Registered Nurse

Posted: 2020-10-04 Expires: 2020-11-02
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Initial Clinical Reviewer - RN - IPM/MSK

Magellan Health
Maryland Heights, MO 63043

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Registered Nurse
118th2018 - Registered Nurse
Overall Rating: 118/220
Median Salary: $70,000

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