Utilization Review Clinician - Behavioral Health

Centene • Lexington, KY

394d • $54,018 - $97,094

About The Position

The Utilization Review Clinician for Behavioral Health at Centene is responsible for performing clinical reviews and assessments related to mental health and substance abuse. This role involves monitoring the appropriateness of care levels and services, conducting prior authorization reviews, and engaging with healthcare providers to ensure quality care for members. The clinician will analyze member data to enhance service utilization and provide education to stakeholders about the behavioral health utilization process.

Requirements

• Graduate of an Accredited School of Nursing or Bachelor's degree with 2 - 4 years of related experience.
• License to practice independently or state-required licensure as outlined by applicable state requirements.
• Master's degree for behavioral health clinicians required.
• Clinical knowledge and ability to review and 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.
• LCSW, LMHC, LPC, LMFT, LMHP, or RN state licensure required.

Nice To Haves

• Clinical knowledge and ability to review and 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.

Responsibilities

• Perform clinical reviews and assess care related to mental health and substance abuse.
• Monitor and determine if the level of care and services are medically appropriate.
• Evaluate member's treatment for mental health and substance abuse before, during, and after services.
• Conduct prior authorization reviews to determine medical appropriateness in accordance with regulatory guidelines.
• Perform concurrent reviews of behavioral health inpatient cases to assess member health and treatment needs.
• Analyze behavioral health member data to improve quality and appropriate utilization of services.
• Provide education to providers, members, and their families regarding the behavioral health utilization process.
• Interact with behavioral health healthcare providers to discuss levels of care and services.
• Engage with medical directors and leadership to improve care quality and efficiency.
• Formulate and present cases in staffing and integrated rounds.
• Comply with all policies and standards.

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible work schedules including remote, hybrid, field, or office work.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees