Utilization Review Clinician - Behavioral Health
About The Position
Centene is seeking a clinical professional for its Medical Management/Health Services team to perform clinical reviews and assess care related to mental health and substance abuse. The role involves monitoring and determining the medical appropriateness of the level of care and services provided for mental health and substance abuse. The position evaluates member treatments before, during, and after services, performs prior authorization reviews, and conducts concurrent reviews of behavioral health inpatient cases. It also involves analyzing member data to improve quality and utilization, educating providers and members, interacting with healthcare providers, and collaborating with medical directors and leadership. The role requires formulating and presenting cases in staffing and integrated rounds, performing other duties as assigned, and complying with all policies and standards.
Requirements
- Graduate of an Accredited School Nursing or Bachelor's degree
- 2 – 4 years of related experience
- License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state required.
- Master’s degree for behavioral health clinicians required.
- LCSW- License Clinical Social Worker required or
- LMHC-Licensed Mental Health Counselor required or
- LPC-Licensed Professional Counselor required or
- Licensed Marital and Family Therapist (LMFT) required or
- Licensed Mental Health Professional (LMHP) required or
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required
- Must be available to work Monday-Friday, 8:00 a.m.-5:00 p.m. CST, with occasional weekend and holiday coverage as needed.
Nice To Haves
- Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse preferred.
- Knowledge of mental health and substance abuse utilization review process preferred.
- Experience working with providers and healthcare teams to review care services related to mental health and substance abuse preferred.
Responsibilities
- 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 regrading 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
- 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
