Job Description

Job Description

Job Description

Job Description: Clinical Quality of Care Reviewer/Social Worker

Position Overview

The Clinical Quality of Care Reviewer is responsible for conducting comprehensive, timely, and objective reviews of clinical assessments and supporting documentation to evaluate quality of care concerns, identify potential risks, and support the health, safety, and well-being of individuals with developmental disabilities.

This position operates within a quality management framework and follows established review protocols, documentation standards, and regulatory requirements. The reviewer analyzes information from multiple sources, evaluates clinical needs, develops evidence-based recommendations, and identifies opportunities for corrective action or additional oversight when appropriate.

Positions are primarily remote and require an active professional license in the State of Arizona. Work schedules and assignment volumes may vary based on operational needs, case volume, and staffing requirements.

Key Responsibilities

• Conduct timely, thorough, and objective clinical reviews in accordance with established quality management procedures.
• Review clinical assessments, medical records, supporting documentation, and information provided by individuals or their authorized health care decision-makers.
• Evaluate complex medical, developmental, behavioral, and functional needs using clinical judgment and discipline-specific expertise.
• Identify potential quality of care concerns, safety risks, service gaps, and opportunities for improvement.
• Synthesize information from multiple sources to develop clear, evidence-based clinical recommendations.
• Document findings, clinical rationale, and recommendations using standardized templates and established review procedures.
• Request additional documentation or clarification when necessary to complete a comprehensive review.
• Consult with professionals from other disciplines when additional expertise is needed.
• Identify cases requiring further evaluation, escalation, or referral to appropriate oversight or regulatory agencies.
• Recognize trends and systemic concerns and communicate significant findings to designated supervisors or quality management personnel.
• Support the development and implementation of corrective action recommendations when warranted.
• Maintain complete, accurate, and confidential case documentation in accordance with applicable policies and requirements.
• Identify and disclose potential conflicts of interest.
• Respond promptly to assignments, requests for clarification, and additional information requests.
• Complete assigned reviews within required timelines.

Consultative Clinical Responsibilities

Qualified professionals, including social workers, Board Certified Behavior Analysts (BCBAs), and occupational therapists, may provide consultation within their respective areas of expertise when requested by the primary physician reviewer.

Consultative responsibilities include:

• Provide discipline-specific clinical insight and recommendations.
• Review relevant information within the scope of professional expertise.
• Assist with interpreting clinical, behavioral, functional, or psychosocial needs.
• Respond to consultation requests in a timely manner.
• Support the primary reviewer in developing informed clinical recommendations.

Consultative professionals do not serve as primary reviewers or certify cases. Assignment volume, consultation frequency, and work hours are not guaranteed and will depend on operational needs.

Required Qualifications

• An active, unrestricted professional license appropriate to the assigned role and valid for practice in the State of Arizona.
• Education and professional credentials consistent with applicable licensing requirements.
• Ability to complete required training and follow standardized review, documentation, and certification procedures.
• Ability to identify potential conflicts of interest and comply with applicable confidentiality and professional standards.
• Strong clinical judgment, analytical reasoning, and decision-making skills.
• Ability to synthesize complex information from multiple sources and produce clear, professional documentation.
• Ability to manage assignments independently and meet established deadlines.

Social Workers

• Master’s degree in social work.
• Appropriate Arizona licensure, including LMSW or LCSW, as applicable to the assigned role.

Job Tags

Similar Jobs