Utilization Review Clinician - Behavioral Health

Centene Corporation • Remote-FL, FL

1d • $27 - $49

About The Position

Performs clinical reviews and assesses care related to mental health and substance abuse, monitoring and determining whether the level of care and services are medically appropriate. Evaluates member treatment before, during, and after services, conducts prior authorization and concurrent reviews, analyzes behavioral health member data to support quality and appropriate utilization, and provides education about the behavioral health utilization process. The role works with providers, members, families, medical directors, and leadership to support appropriate care and improve quality and efficiency.

Requirements

• Graduate of an accredited school of nursing or a bachelor's degree, with 2–4 years of related experience.
• License to practice independently and/or state-required licensure as applicable.
• Master’s degree required for behavioral health clinicians.
• Required license or certification: LCSW, LMHC, LPC, LMFT, LMHP, or RN with state licensure and/or compact state licensure.
• For Fidelis Care only: LMSW, LCSW, LMHC, LPC, LMFT, LMHP, or RN is required.

Nice To Haves

• 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 processes.
• 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 determine whether the level of care and services are medically appropriate.
• Perform prior authorization reviews related to mental health and substance abuse in accordance with regulatory guidelines and criteria.
• Perform concurrent reviews of behavioral health inpatient care to assess 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 to discuss level 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.
• Perform other duties as assigned.
• Comply with all policies and standards.

Benefits

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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level