Utilization Review Clinician - Behavioral Health
About The Position
Centene is seeking a remote Utilization Review Clinician to support its inpatient and outpatient Behavioral Health Medicare Plan. The role performs clinical reviews and assesses mental health and substance abuse care, monitoring and determining whether the level of care and services are medically appropriate. It conducts medical necessity reviews and authorization determinations to help ensure members receive appropriate, high-quality behavioral health services. The clinician evaluates treatment before, during, and after services; performs prior authorization and concurrent inpatient reviews; analyzes member data to support quality and appropriate utilization; and communicates with providers, members, and families about the utilization process. The position also works with medical directors and leadership to improve care quality and efficiency and presents cases in staffing and integrated rounds. The schedule is Monday through Friday, 8:00 AM–5:00 PM EST. The stated pay range is $27.02–$48.55 per hour. Centene describes a comprehensive benefits package and equal opportunity employment practices.
Requirements
- Graduate of an accredited school of nursing or a bachelor's degree, and 2–4 years of related experience.
- License to practice independently and/or state-required licensure as applicable.
- A master's degree is required for behavioral health clinicians.
- One of the following required licenses/certifications: LCSW, LMHC, LPC, LMFT, LMHP, or RN with state licensure and/or compact state licensure.
Nice To Haves
- Behavioral health and/or utilization management 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 mental health and substance abuse care services.
- Strong knowledge of medical necessity criteria and managed care principles.
Responsibilities
- Evaluate members’ mental health and substance abuse treatment before, during, and after services to determine whether the level of care and services are medically appropriate.
- Perform prior authorization reviews for mental health and substance abuse care in accordance with regulatory guidelines and criteria.
- Conduct concurrent reviews of behavioral health inpatient care to assess the member’s 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 to discuss level of care and/or services.
- Work 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)
- Stock purchase plans
- Tuition reimbursement
- Paid time off
- Holidays
- 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
