Utilization Review Clinician - Behavioral Health

Centene Corporation

22h

About The Position

Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. This role is for a clinical professional on their Medical Management/Health Services team. The position involves performing clinical reviews and assessing care related to mental health and substance abuse, monitoring and determining if the level of care and services are medically appropriate, and evaluating member's treatment before, during, and after services. It operates within a Behavioral Health UR Clinical Call Center Environment with 365/24-7 coverage, requiring applicants to work Monday - Friday: 8 am – 5pm (CST).

Requirements

License to practice independently and have obtained the state required licensure as outlined by the applicable state.
Graduate of an Accredited School Nursing or Bachelor's degree and 2 – 4 years of related experience.
Master's degree AND 2 - 4 years of related behavioral health and/or substance abuse addiction disorders experience.
LCSW - License Clinical Social Worker required or LPC- Licensed Professional Counselor required or LMFT - Licensed Marital and Family Therapist required or RN - Registered Nurse - State Licensure and/or Compact State Licensure required.
Ability to work Monday - Friday: 8 am – 5pm (CST).
Direct behavioral health/psychiatric experience.

Nice To Haves

Graduate of an Accredited Master’s degree - Behavioral Health related field.
Direct experience with Utilization Review or Utilization Management related to Behavioral Health case.
Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse.
Experience working with providers and healthcare teams to review care services, precertification, concurrent review, discharge reviews for mental health and substance abuse cases.
Direct IOP Behavioral Health and/or SUD inpatient hospital experience.
Experience in Behavioral Health Case Management or Utilization Management in Managed Care Organizations, In-Patient Behavioral Health Units, Partial Hospitalization, or Residential Treatment.

Responsibilities

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.
Performs other duties as assigned.
Complies with all policies and standards.