Clinical Reviewer (Remote)

Maximus; Minneapolis (MN); Remote; USD 80,000 - 100,000; Full time

Job summary

An established industry player is looking for a dedicated Clinical Reviewer to join their remote team. In this role, you will conduct clinical reviews of PASRR screens, ensuring compliance with state and federal guidelines. You'll be part of a collaborative team, evaluating individual needs for comprehensive assessments and making critical decisions regarding approvals and denials. This position offers the opportunity to work independently while contributing to the health and well-being of individuals with serious mental illnesses. If you are detail-oriented and passionate about making a difference, this role is perfect for you.

Qualifications

• Minimum 1 year of clinical experience required.
• Knowledge of community support programs and long-term care assessment.

Responsibilities

• Review requests for services for adherence to clinical criteria.
• Issue approvals, denials or recommendations based on contract requirements.
• Communicate with providers and state workers as required.

Skills

Communication Skills

Interpersonal Skills

Organizational Skills

Attention to Detail

Data Collection and Analysis

Knowledge of Medical Diagnoses

Customer Service Skills

Education

High School Degree or equivalent

LPN, RN, LCSW or related licensure

Master's degree in Social Work or related field

Tools

Microsoft Office Suite

Job description

Maximus is seeking a dedicated and detail-oriented Clinical Reviewer to support the Colorado PASRR Program. In this remote role, you will be responsible for conducting a clinical review of Level I PASRR screens, evaluating the completed screen, making determinations regarding an individual's need for a more comprehensive PASRR assessment, and ensuring compliance with state and federal guidelines.

• This is a fully remote position!

About the program: Maximus is contracted with Colorado Department of Health Care Policy and Financing to manage the statewide CO PASRR program. Starting July 2025, we will begin managing submission of all Level I PASRR referrals and Status Changes, completion of clinical review to determine if a person has a known or suspected PASRR condition (SMI, ID or related condition), completion of the comprehensive person-centered Level II assessments. This role will be part of a collaborative team of professionals, working remotely, and will be responsible for completing the clinical review portion of the process and determining if a referred individual has one of the PASRR conditions.

Essential Duties and Responsibilities:

• Review requests for services including admission, discharges and continued stays for adherence to clinical criteria, state and federal policy, and related requirements.
• Issue approvals, denials or recommendations based on contract requirements.
• Identify need for additional clinical documentation or consultation.
• Complete documentation of activities within contract systems.
• Communicate with providers, individuals and their designees, or state workers as required.
• Performs other related duties as assigned.

Required Skills / Abilities:

• Preferred knowledge may include community support programs, long-term care assessment and level of care in medical, behavioral health or related programs.
• Knowledge and understanding of medical and/or behavioral health diagnoses and prescribed medications.
• Ability to collect data, define problems, establish facts, and draw valid conclusions.
• Excellent written and verbal communication skills.
• Excellent interpersonal and customer service skills.
• Proficient in Microsoft Office Suite.
• Excellent organizational skills and attention to detail.
• Ability to work in a fast-paced environment.
• Ability to work independently and meet timelines.
• High School Degree or equivalent required.
• Minimum 1 year of clinical experience required.
• LPN, RN, LCSW, or related licensure preferred and may be required based on contract requirements.
• Master's degree in Social Work, Mental Health, or in a related field or RN with psychiatric experience.
• Minimum 1-2 years of experience working with individuals with serious mental illness (SMI), in the adult/older adult services field, or with chronic medical conditions.
• Minimum 1 year experience conducting mental health assessments or clinical review.

Home Office Requirements:

• Reliable high-speed internet service.
• Minimum 20 Mpbs download speeds / 50 Mpbs for shared internet connectivity.
• Minimum 5 Mpbs upload speeds.
• Private and secure workspace.