Behavioral Health Utilization Review Specialist

Gainwell Technologies LLC•Any city, OH

6d•$90,900 - $129,900•Remote

About The Position

The Behavioral Health Utilization Review Specialist adjudicates behavioral health prior authorizations based on medical necessity and eligibility, following State policy guidelines and accepted best practices. Specialty areas include Substance Use Disorder Treatment, Child and Adolescent Day Treatment, Adult Mental Health Day Treatment, and In-Home Family Therapy. The role provides utilization review and quality assurance and does not involve direct patient interactions. The specialist reviews submissions using multiple computer systems, records authorization outcomes in the Medicaid Management Information System (MMIS), and may request additional information or clarification from providers. The position also supports providers through education, participates in stakeholder meetings, reviews policy communications, and recommends process improvements. This is a full-time, 100% remote home-office position.

Requirements

Master’s degree in counseling, social work, marriage and family therapy, or equivalent.
At least 5 years of clinical work experience.
Current LPC, LCSW, or LMFT license in Wisconsin, or a license from another state and ability to obtain a Wisconsin license before the position start date.
CSAC or SAC license in Wisconsin; CSAC is preferred.
Excellent computer skills.
Excellent interpersonal, oral, and written communication skills.
Ability to meet deadlines and manage priorities with minimal direct supervision.
Experience working with partners or team members toward shared goals.
Ability to communicate effectively and interpret policies and procedures.

Nice To Haves

Knowledge of or experience with the Wisconsin Medicaid program or another state’s Medicaid program.
Previous Utilization Management-Review experience.
CSAC license in Wisconsin.

Responsibilities

Review and evaluate prior authorization submissions using multiple computer systems, seeking additional information or clarification from requesting providers when appropriate.
Enter prior authorization outcomes into the Medicaid Management Information System (MMIS) for processing.
Participate in monthly meetings with leadership, operational staff support, clinical peers, and State of Wisconsin stakeholders.
Provide assistance and education to the provider community regarding specific prior authorization submissions, when applicable.
Analyze and recommend methods and potential process improvements related to administration and application of supported medical programs.
Review communications to providers and members about new or revised policies.