This is a fully remote position, open to applicants in Florida.

📋 Description

• Perform clinical file assessments by analyzing clinical documentation to ensure required clinical adherence.

• Review care management member interactions through call recordings and associated documentation to conduct audits.

• Engage in the creation and continuous evaluation of clinical review tools.

• Assess program descriptions, policies and procedures, step actions, training materials, and State Contracts for alignment with standards.

• Analyze documentation of member health assessments, clinical needs, and interventions to ensure compliance with established standards.

• Attend meetings to discuss review outcomes, potential areas for improvement, and provide recommendations.

• Raise concerns identified during clinical file reviews for escalation.

• Aid in the preparation for State, CMS, and NCQA audits.

• Achieve set productivity and Interrater Reliability standards for file reviews.

• Adhere to departmental guidelines and processes.

• Carry out additional duties as assigned.

⛳️ Requirements

• A Bachelor's Degree in Nursing, Clinical Social Work/Counseling is required, OR an Associate's degree with an RN and a minimum of 3 years of clinical experience.

• At least 3 years of experience in a clinical setting (inpatient or outpatient) is required.

• A valid license is necessary as a Licensed Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), Licensed Mental Health Counselor (LMHC), or Licensed Marital and Family Therapist (LMFT).

• Preferred: 1+ year of experience in Managed Care (UM, BH, CM).

• Familiarity with Medicare and Medicaid programs is preferred.

• Certification as a Case Manager (CCM) is preferred.

• Strong attention to detail is essential.

• Experience in evaluating clinical documentation and assessing call quality is required.