Magellan Health is the leader in managing complex population health, concentrating on all areas across healthcare and pharmaceutical management.
At Magellan Health, 10,000 people wake up every day determined to help our members. We do this by connecting behavioral, physical, pharmacy and social needs into a complete picture of care that’s personalized, coordinated and cost-effective. By turning fragmented care into focused care, we empower 1 in 10 Americans to lead healthier, more vibrant lives.
Magellan Health Remote
Oct 24, 2021
Key member of the utilization management team, and provides timely medical review of service requests that do not initially meet the applicable medical necessity guidelines. Routinely interacts with physicians, leadership and management staff, other Physician Clinical Reviewers (PCR), and health plan members and staff whenever a physician`s input is needed or required. Directs daily involvement in the following utilization management functions: Reviews all cases in which clinical determinations cannot be made by the Initial Clinical Reviewer. Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory time frame of the request by phone or fax. Provides clinical rationale for standard and expedited appeals. Provides assistance and act as a resource to Initial Clinical Reviewers as needed to discuss cases and problems. Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD...
Magellan Health Remote
Oct 05, 2021
Registered Nurse Licensed Clinical Social Worker
Under general supervision, and in collaboration with other members of the clinical team, authorizes and reviews utilization of mental health and substance abuse services provided in inpatient and/or outpatient care settings. Collects and analyzes utilization data. Assists with discharge planning and care coordination. Provides member assistance with mental health and substance abuse issues, and participates in special quality improvement projects. Monitors inpatient and/or outpatient level of care services related to mental health and substance abuse treatment to ensure medical necessity and effectiveness. Provides telephone triage, crisis intervention and emergency authorizations as assigned. Performs concurrent reviews for inpatient and/or outpatient care and other levels of care as allowed by scope of practice and experience.  In conjunction with providers and facilities, develops discharge plans and oversee their implementation.  Performs...