Utilization Review Clinician - Behavioral Health
About The Position
Centene is seeking a clinical professional for its Medical Management/Health Services team to review care related to mental health and substance abuse for its members. This fully remote role requires independent clinical licensure and focuses on settings such as residential treatment centers, inpatient psychiatric admissions, detox, crisis stabilization units, PHP, and community-based services. The position involves monitoring and determining the medical appropriateness of care and services, performing prior authorization and concurrent reviews, analyzing member data, educating providers and members, and collaborating with medical directors and leadership. Preference is given to applicants with experience in utilization management/review, behavioral health settings, and specific knowledge of the Mississippi market or related services.
Requirements
- Graduate of an Accredited School Nursing or Bachelor's degree and 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.
Nice To Haves
- Reside ideally in Mississippi, Louisiana, Arkansas, Texas, or Tennessee.
- Experience in utilization management/review.
- Experience in behavioral health settings.
- Experience with Mississippi market, managed care, Mental Health Residential Services for children, or Juvenile Sex Offender Program.
- Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse.
- Knowledge of mental health and substance abuse utilization review process.
- Experience working with providers and healthcare teams to review care services related to mental health and substance abuse.
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 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
