Utilization Review Clinician - Behavioral Health
About The Position
Performs a clinical review and assesses care related to mental health and substance abuse. Monitors and determines if level of care and services related to mental health and substance abuse are medically appropriate. Evaluates member’s treatment for mental health and substance abuse before, during, and after services to ensure level of care and services are medically appropriate. Performs prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria. Performs concurrent review of behavioral health (BH) inpatient to determine overall health of member, treatment needs, and discharge planning. Analyzes BH member data to improve quality and appropriate utilization of services. Provides education to providers, members, and their families regarding BH utilization process. Interacts with BH healthcare providers as appropriate to discuss level of care and/or services. Engages with medical directors and leadership to improve the quality and efficiency of care. Formulates and presents cases in staffing and integrated rounds. Complies with all policies and standards.
Requirements
- License to practice independently and have obtained the state required licensure as outlined by the applicable state is required
- Requires Graduate of an Accredited School Nursing or Bachelor's degree and 2 – 4 years of related experience.
- Requires Graduate of an Accredited Master’s degree - Behavioral Health related field is preferred
- Master's degree AND 2 - 4 years of related behavioral health and/or substance abuse addiction disorders experience is required.
- Clinical knowledge and ability to review and/or assess patients’ SPMI needs based on ASAM criteria is required
- Direct work experience with patients receiving care in IOP Behavioral Health settings, SUD Detox facilities, SUD Residential services, Partial Hospitalization services, or Managed Care organizations
- LPC, LCSW, LMFT, or RN Applicants may reside in other states, but must have their clinical license issued from the state of Texas.
- LCSW - License Clinical Social Worker required for Texas
- LPC- Licensed Professional Counselor required for Texas
- LMFT - Licensed Marital and Family Therapist required for Texas
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required for Texas
Nice To Haves
- Experience with Utilization Review, Utilization Management related to Behavioral Health cases is preferred.
Responsibilities
- Performs prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria
- Performs concurrent review of behavioral health (BH) inpatient to determine overall health of member, treatment needs, and discharge planning
- Analyzes BH member data to improve quality and appropriate utilization of services
- Provides education to providers, members, and their families regarding BH utilization process
- Interacts with BH healthcare providers as appropriate to discuss level of care and/or services
- Engages with medical directors and leadership to improve the quality and efficiency of care
- Formulates and presents cases in staffing and integrated rounds
- Performs other duties as assigned
- Complies with all policies and standards
Benefits
- competitive pay
- health insurance
- 401K and stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- a flexible approach to work with remote, hybrid, field or office work schedules
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
5,001-10,000 employees
