Clinical Reviewer LPN - (Remote)

Description & Requirements

• Essential Duties and Responsibilities: - Review requests for services, including admissions, discharges, and continued stays for adherence to clinical criteria, state and federal policy, and contract requirements involving broad clinical complexity and variability; apply subject matter expertise to ensure consistency and drive quality outcomes; and escalate exceptions to policies. - Issue approvals, denials, or recommendations based on contract requirements; ensure quality, consistency, and adherence to clinical and regulatory standards across cases. - Identify the need for additional clinical documentation or consultation and analyze information gaps to support accurate and timely determinations. - Complete accurate documentation of review activities within contract systems. - Communicate and collaborate with providers, individuals and their designees, state workers, and external stakeholders to clarify requirements, resolve issues, and support program outcomes. - Provide guidance, coaching, training and quality review for team members; identify opportunities to improve review processes and consistency. - May meet with external clients to confirm and update clinical guidelines that must be followed internally. - May write high-quality, fully substantiated clinical determination reports by synthesizing assessment findings, interview data, and supporting documentation, including completing the summary of findings.