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Utilization Review Clinician – Behavioral Health
Centene CorporationUtilization Review Clinician providing medical necessity reviews and authorization determinations for behavioral health services. Ensuring high-quality care for Indiana Medicaid Plan members under Centene organization.
ATS Keywords
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Hard Skills
medical necessity reviewsauthorization determinationsclinical reviewprior authorization reviewsconcurrent reviewbehavioral health data analysistreatment plan assessmentutilization managementmental health assessmentsubstance abuse assessment
Soft Skills
communicationinterpersonal skillscollaborationeducationcase formulationleadershipdischarge planningproblem-solvinganalytical thinkingprovider interaction
Certifications & Qualifications
RN licenseLCSWLMHCLMFTLPC
Industry Keywords
behavioral healthutilization review processmanaged care principlesmental health servicessubstance abuse servicesregulatory guidelineshealthcare providerstreatment needsquality improvementhealthcare teams
About the role
Key responsibilities & impact- Perform medical necessity reviews and authorization determinations to ensure members receive appropriate, high-quality behavioral health services
- Performs a clinical review and assesses care related to mental health and substance abuse
- Monitors and determines if level of care and services related to mental health and substance abuse are medically appropriate
- Evaluates member’s treatment for mental health and substance abuse before, during, and after services
- Performs prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria
- Performs concurrent review of behavioral health (BH) inpatient to determine overall health of member, treatment needs, and discharge planning
- Analyzes BH member data to improve quality and appropriate utilization of services
- Provides education to providers members and their families regarding BH utilization process
- Interacts with BH healthcare providers as appropriate to discuss level of care and/or services
- Engages with medical directors and leadership to improve the quality and efficiency of care
- Formulates and presents cases in staffing and integrated rounds
- Performs other duties as assigned and complies with all policies and standards.
Requirements
What you’ll need- Active RN license or independent clinical licensure (LCSW, LMHC, LMFT, LPC in Indiana)
- Behavioral health and/or utilization management experience preferred
- Strong knowledge of medical necessity criteria and managed care principles
- Graduate of an Accredited School Nursing or Bachelor's degree and 2 – 4 years of related experience
- Master’s degree for behavioral health clinicians required
- Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse preferred
- Knowledge of mental health and substance abuse utilization review process preferred
- Experience working with providers and healthcare teams to review care services related to mental health and substance abuse preferred
Benefits
Comp & perks- competitive pay
- health insurance
- 401K and stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- flexible approach to work with remote, hybrid, field or office work schedules