Clinical Review Clinician

Gaudenzia, Inc.•Washington, DC

6h•$33 - $38

About The Position

Picture Yourself at Gaudenzia as a Clinical Review Clinician at our R.A.P. Program located in Washington D.C.! We are seeking compassionate professionals who are willing to make a difference and serve as a positive role model to those suffering from substance use & co-occurring disorders. The Clinical Review Clinician plays a pivotal role in overseeing the clinical review process for substance use disorder treatment authorizations. This position requires a blend of clinical expertise, leadership skills, and a thorough understanding of utilization management to ensure the highest standards of care and compliance with established guidelines. We are seeking individuals who excel in leadership roles, can work independently, and are adept at managing deadlines. The ideal candidate will have extensive experience in utilization management, as well as familiarity with DC and Comagine. This role involves significant interaction with healthcare providers, internal program management, and external stakeholders to ensure the accuracy and timeliness of clinical reviews. Key responsibilities include supervising the clinical review team, conducting thorough clinical reviews, maintaining accurate records of authorization decisions, and collaborating with other team members to achieve program goals and objectives. The Clinical Review Clinician is also responsible for staying up-to-date with the latest clinical guidelines and best practices, providing training and support to the clinical review team, and ensuring compliance with all regulatory requirements. The work is performed with considerable independence, adhering to established regulations, policies, and procedures. The Clinical Review Clinician reports to the Utilization Management Director, who reviews and supervises the work.

Requirements

Must hold a master’s degree in social work, counseling, psychology, or a related field with active DC independent clinical licensure (e.g. LICSW, LPC, LMFT, or licensed psychologist)
3+ years of clinical practice in substance use. 1+ years of utilization review and/or utilization management or quality assurance.
Knowledge of Managed Care, including DC and Comagine preferred
Knowledge of clinical practices, regulatory, licensing, and accreditation standards
Knowledge of utilization review process
Knowledge and ability to work with electronic health record systems
Knowledge of substance use and mental health disorder treatment programs
Knowledge of quality improvement processes, including the ability to evaluate and recommend changes to enhance service quality
Ability to communicate effectively, both verbally and in writing
Ability to successfully work with others from various cultures and background
Ability to plan and organize work and prepare appropriate, accurate records, and reports
Ability to establish and maintain effective working relationships with clients, staff, health care providers, referral entities, outside agencies, institutions and the general public

Responsibilities

Treat all clients and staff with dignity and respect
Manage and submit the clinical and medical documentation as required for pre-authorization and ongoing authorizations
Supervise initial clinical reviews and provide documented recommendations based on appropriate clinical guidelines
Review and approve initial evaluations and clinical documentation against clinical standards, applicable state regulations, insurance requirements, and relevant treatment guidelines
Ensure accurate, up-to-date records, including intake, records of referral, and funding source documentation are compiled and stored within the electronic health record system within the required timeframes
Assist clinical staff in quality improvement projects by providing instructive feedback within the scope of practice
Resolve patient care issues by working one-on-one with community providers and staff to address issues in the determination process
Establish and maintain positive relationships with funding, referral, and regulatory agencies
Provide information by responding to queries from funding sources, sorting and distributing messages and documents, and preparing information for determinations
Improve quality results by studying and evaluating procedures and processes, and recommending changes if needed.
Other duties as assigned by the Clinical Director, or designee