Utilization Review Clinician Jobs

About The Position

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 the state-required licensure applicable to the position.
• A master's degree is required for behavioral health clinicians.
• One of the following licenses/certifications is required: LCSW, LMHC, LPC, LMFT, LMHP, or RN with state and/or compact state licensure.
• For Fidelis Care, 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 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 member treatment for mental health and substance abuse before, during, and after services to ensure the level of care and services are medically appropriate.
• Perform prior authorization reviews for mental health and substance abuse services in accordance with regulatory guidelines and criteria.
• Perform concurrent reviews of behavioral health inpatient care to determine 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 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 and 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 approach to work with remote, hybrid, field, or office work schedules