Utilization Review Clinician - Behavioral Health
About The Position
Performs clinical reviews and assesses care related to mental health and substance abuse, monitoring and determining whether levels of care and services are medically appropriate. The clinician evaluates treatment before, during, and after services; conducts prior authorization and concurrent reviews; analyzes behavioral health data; and collaborates with providers, members, families, medical directors, and leadership to support appropriate, quality, and efficient care. This is a fully remote position with availability required Monday through Friday, 8:30 a.m. to 5:00 p.m. Eastern Time. Candidates must hold an active, applicable clinical license; New York State licensure is strongly preferred.
Requirements
- Graduation from an accredited school of nursing or a bachelor’s degree.
- 2–4 years of related experience.
- License to practice independently and/or the state-required licensure applicable to the role.
- For behavioral health clinicians, a master’s degree is required.
- For Fidelis Care only: LMSW, LCSW, LMHC, LPC, LMFT, LMHP, or RN is required.
- Availability Monday through Friday from 8:30 a.m. to 5:00 p.m. Eastern Time.
- An active, applicable clinical license.
Nice To Haves
- New York State licensure is strongly preferred.
- 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 in accordance with regulatory guidelines and criteria.
- Conduct 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 levels of care and/or services, as appropriate.
- 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
- 401K plan
- Stock purchase plan
- Tuition reimbursement
- Paid time off and holidays
- Flexible approach to work schedules, including remote, hybrid, field, or office schedules
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
