Behavioral Health Utilization Management Review

Amerihealth Caritas•, LA

4d•Remote

About The Position

Under the direction of the Supervisor, the Behavioral Health Utilization Management (BHUM) Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and experience, the clinician reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the BH UM Reviewer’s discretion to retain requests for additional information and/or request clarification. The BH UM Reviewer will use professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases to integrated care management as needed. The BH UM Reviewer will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when indicated. The BH UM Reviewers are responsible to ensure that treatment delivered is appropriately utilized and meets the member’s needs in the least restrictive, least intrusive manner possible. The BH UM Reviewer will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and uses clinical judgment in their application.

Requirements

Associate Degree in Nursing required (for RN candidates)
Master Degree in Social Work required (for Licensed Social Worker candidates)
Minimum of 2 years of independent clinical practice experience assessing and treating individuals with mental health/substance use/co-occurring disorders in a partial hospitalization program (PHP), intensive outpatient program (IOP) and/or residential treatment program.
Active and unencumbered LCSW and/or LPC in Louisiana
Active and unencumbered multi-state Registered Nurse license (e-NLC)
Proficiency in Microsoft Office, including Word, Excel, Teams, and Outlook
Consistent and accurate typing skills
Ability to communicate in a positive/professional manner both orally and written
Strong problem-solving skills and decision making skills
Strong organizational and time management skills
Ability to follow detailed instructions with a high degree of accuracy
Ability to work independently; complete tasks in the allotted time frame
Access to a reliable high-speed internet connection (minimum bandwidth of 50 Mbps download and 5 Mbps upload)

Nice To Haves

Bachelor Degree in Nursing preferred (for RN candidates)
Utilization management experience in a managed care organization preferred
Experience working in a remote work environment preferred

Responsibilities

Completing medical necessity reviews
Reviewing provider requests for inpatient and outpatient services
Working closely with members and providers to collect all information necessary to perform a thorough medical necessity review
Retaining requests for additional information and/or requesting clarification
Using professional judgment to evaluate requests to ensure appropriate services are approved
Recognizing care coordination opportunities and referring those cases to integrated care management as needed
Applying medical health benefit policy and medical management guidelines to authorize services
Appropriately identifying and referring requests to the Medical Director when indicated
Ensuring that treatment delivered is appropriately utilized and meets the member’s needs in the least restrictive, least intrusive manner possible
Maintaining current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and using clinical judgment in their application