Utilization Review Clinician - Behavioral Health
About The Position
The Utilization Review Clinician performs clinical reviews of mental health and substance abuse care to determine whether the level of care and services are medically appropriate. This fully remote role supports the California Market, while applicants in other states may be considered if they can work the required training schedule and one of the designated main schedules. Training is Monday through Friday, 8 a.m. to 5 p.m. for the first few weeks. California residents may work Thursday through Monday or Friday through Tuesday, 9:30 a.m. to 6 p.m. Pacific Time. Non-California residents may work Friday through Monday, 7:30 a.m. to 6 p.m. Pacific Time, with a 30-minute lunch break. Schedules include rotating holidays and occasional overtime. Preference is given to applicants with behavioral health and utilization management or review experience. The role evaluates members’ treatment before, during, and after services; conducts prior authorization and concurrent reviews; analyzes member data to support quality and appropriate service utilization; and communicates with providers, members, families, medical directors, and leadership. The clinician also presents cases in staffing and integrated rounds, performs other assigned duties, and complies with all policies and standards.
Requirements
- Graduate of an accredited nursing school or a bachelor's degree.
- Two to four years of related experience.
- Independent practice license and/or state-required licensure, as applicable.
- A master's degree is required for behavioral health clinicians.
- One of the following credentials is required: LCSW, LMHC, LPC, LMFT, LMHP, or RN with state licensure and/or compact state licensure.
- Ability to work the specified training schedule and one of the designated main schedules; schedules include rotating holidays and occasional overtime.
Nice To Haves
- Behavioral health and utilization management or review experience.
- Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse.
- Knowledge of the 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
- Evaluate members’ mental health and substance abuse treatment before, during, and after services to ensure the level of care and services are medically appropriate.
- Perform prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria.
- Perform concurrent reviews of behavioral health inpatient care to determine members’ overall health, treatment needs, and discharge planning.
- Analyze behavioral health member data to improve quality and appropriate utilization of services.
- Educate providers, members, and their families about the behavioral health utilization process.
- Interact with behavioral health healthcare providers as appropriate to discuss level of care and/or services.
- Engage with medical directors and leadership to improve the quality and efficiency of care.
- Formulate and present cases in staffing and integrated rounds.
- Perform other duties as assigned.
- Comply with all policies and standards.
Benefits
- Competitive pay.
- Health insurance.
- 401(k) and stock purchase plans.
- Tuition reimbursement.
- Paid time off and holidays.
- Flexible work approach with remote, hybrid, field, or office work schedules.
- Additional forms of incentives may be included in total compensation.
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What This Job Offers
Job Type
Full-time
