Behavioral Health Clinical Reviewer

Position Summary

The Behavioral Health Clinical Reviewer is responsible for evaluating clinical records and referral documentation to determine eligibility and fit for Nexus behavioral health and neurodevelopmental programs. This role involves preparing high-quality clinical evaluations and summaries that meet payer requirements, including insurance and Medicaid standards. The reviewer ensures admissions decisions are made efficiently, accurately, and in compliance with regulatory, clinical, and Nexus program guidelines.

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Key responsibilities

• Referral & Record Review
• Review incoming referral packets, medical and clinical histories, assessments, and related documentation.
• Determine program appropriateness for behavioral health, autism, intellectual/developmental disabilities, and medically complex cases.

• Funder & Payer Compliance
• Maintain up-to-date knowledge of insurance and Medicaid documentation standards.
• Draft clinical documentation that addresses payer expectations and anticipates potential questions or objections.

• Collaboration & Communication
• Partner with referral sources, families, and internal teams to clarify information and obtain missing documentation.
• Clearly communicate admission decisions and next steps.

• Timeliness & Quality
• Process referrals and evaluations promptly while maintaining clinical accuracy and compliance.
• Balance efficiency with quality, ethics, and thoroughness.

• Continuous Learning & Improvement
• Stay current on behavioral health conditions, neurodevelopmental disorders, and medical complexities.
• Monitor evolving payer policies, assessment tools, and evidence-based practices.

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Qualifications

• Education
• Master’s degree in Social Work, Clinical Psychology, Counseling, Applied Behavior Analysis, or a related behavioral health field; or Bachelor’s degree in Nursing.
• Doctoral degree (PhD, PsyD, DSW) preferred but not required.