About the position
The BH Utilization Management Reviewer position at Partners Health Management is a full-time role that offers a remote work option. The primary purpose of this position is to evaluate the medical necessity, appropriateness, and efficiency of services requested for authorization against established criteria adopted by the Local Management Entity/Managed Care Organization (LME/MCO). The reviewer will respond to all requests for authorizations from the provider community, ensuring that decisions are guided by medical necessity and clinical guidelines. Services will be authorized based on individual needs and standardized procedures, which include reviewing and authorizing initial requests, concurrent requests, urgent requests, and retrospective requests. In this role, the reviewer will consult with providers regarding authorization requests and collaborate with Partners BHM physicians when there are questions about authorization, enrollee health and safety issues, medication issues, or the need for peer review. The reviewer will also be responsible for developing letters that communicate the reasons for any adverse decisions to enrollees and providers, as well as providing information regarding options to appeal these decisions. This position requires a comprehensive knowledge of mental illness, appropriate treatment for major diagnostic categories, and behavioral health principles, techniques, and practices. The reviewer must also be familiar with person-centered and recovery philosophies, assessments and interventions for mental health, developmental disabilities, and substance use disorders, as well as psychiatric medications and evidence-based practices. The ideal candidate will possess excellent computer skills, particularly in Microsoft Office products, and have the ability to engage providers in collegial discussions about care plans and best clinical practices. Strong communication skills, both oral and written, are essential, as is the ability to manage multiple tasks and priorities effectively under pressure. The position requires a Master's Degree in a Human Services field with clinical licensure and two years of post-Master's experience in behavioral health, or a Registered Nurse with two years of experience in behavioral health post-RN degree. Candidates must reside in North Carolina and hold the appropriate licensure to practice in the state.
Responsibilities
- Evaluate medical necessity, appropriateness, and efficiency of services requested for authorization.
- Respond to all requests for authorizations from the provider community with appropriate decisions guided by medical necessity and clinical guidelines.
- Review and authorize initial requests, concurrent requests, urgent requests, and retrospective requests.
- Consult with providers regarding authorization requests.
- Collaborate with Partners BHM physicians regarding authorization questions, enrollee health and safety issues, and medication issues.
- Develop letters communicating reasons for adverse decisions and options for appeal.
Requirements
- Master's Degree in a Human Services field with clinical licensure and two years of post-Master's experience in behavioral health, or a Registered Nurse with two years of experience in behavioral health post-RN degree.
- Current unrestricted license with the appropriate professional board of licensure in North Carolina.
- Comprehensive knowledge of mental illness and appropriate treatment for major diagnostic categories.
- Considerable knowledge of person-centered and recovery philosophies and interventions.
- Knowledge of assessments and interventions for mental health, developmental disabilities, and substance use disorders.
- Knowledge of psychiatric medications and side effects.
- Excellent computer skills including proficiency in Microsoft Office products.
Nice-to-haves
- Registered Nurse in North Carolina with experience in psychiatric nursing services.
- Dual licensed with one of the specialties listed (LCSW, LCMHC, LPA, LMFT).
Benefits
- Paid holidays
- Disability insurance
- Health insurance
- Dental insurance
- Vision insurance
- 401(k) matching
- Annual incentive bonus plan
- Generous vacation and sick time accrual
- State Retirement (pension plan)
- Company paid life and disability insurance
- Wellness Programs
