Quality Clinical Reviewer, Licensed/Remote in PA (Cambria Cty)

About the position

The Quality Clinical Reviewer position at Magellan Health Services is a remote role based in the Cambria County area of Pennsylvania. The primary focus of this role is to conduct thorough reviews of clinical interactions and documentation, ensuring compliance with established quality standards and regulations. The reviewer will analyze data for continuous quality improvement and engage with various stakeholders to enhance the quality of care provided.

Responsibilities

• Conduct reviews of clinical interactions and clinical documentation including case management records and provider treatment records.
• Collect data following established procedures and analyze findings for continuous quality improvement and reporting.
• Interact with multiple stakeholders internally and externally regarding clinical reviews.
• Audit and review case manager and provider clinical documentation against regulations and accreditation standards.
• Evaluate provider treatment records against established clinical and procedural standards.
• Monitor quality of care standards in the provider network and for care managers.
• Conduct reviews of Quality of Care and Critical/Adverse Incidents.
• Assess patient safety risks and determine follow-up actions as per policies.
• Collect, analyze, and prepare clinical record information for efficiency and quality assessment projects.
• Prepare monthly performance reports and present findings at provider and customer meetings.
• Assist in planning and implementing activities to improve service delivery and quality of care, including developing in-service education programs for providers and care managers.
• Audit and validate internal audit results and corrective action plans.

Requirements

• Bachelor's level clinician (RN) or master's level clinician (LCSW, LPC, LMHC, MFT) required.
• 5+ years of clinical experience required.
• 7 or more years of clinical experience along with an associate's degree and RN licensure may substitute for the bachelor's degree and RN licensure.
• Experience in total quality improvement or behavioral healthcare background in treatment modalities and psychopharmacology.
• Familiarity with federal/state regulatory guidelines and performance measurement.
• Ability to work independently with minimal supervision.
• Project management skills and demonstrated experience.

Nice-to-haves

• PsyD in Clinical Psychology preferred.

Benefits

• Comprehensive health benefits
• Life insurance
• Voluntary benefits
• Short-term incentives
• Employee wellness programs