Clinician

• Provide telephonic outreach and support for post-discharge patients
• Conduct assessments and psychosocial evaluations using DSM criteria
• Implement crisis plans and provide interventions for high-risk patients
• Administer clinically validated screening tools and assessments
• Maintain current knowledge of behavioral health and treatment modalities
• Identify and resolve barriers to accessing behavioral health services
• Adhere to professional standards and licensing board ethics
• Communicate with medical staff, leadership, and team members
• Document assessments and progress updates in the medical record
• Exercise clinical judgment and decision-making in a fast-paced environment
• Participate in policy development, implementation, and evaluation
• Collaborate with team members to manage caseload

Telemental health clinician providing post-discharge behavioral health support for Advocate Health

Telemental Health Clinician II – BH Service Line, Virtual Transition Care Team

Telemental health clinician supporting patients after acute behavioral health discharge for Advocate Health. Conducting assessments, crisis interventions, outreach, and care coordination remotely.

• Review clinical information received from providers ensuring clinical data is substantial enough to meet Medical Necessity Criteria to authorize services as needed
• Requires knowledge of medical necessity criteria for behavioral health and substance use services, DMAS protocols, clinical protocols and clinical review requirements.
• Requires knowledge of contractual, regulatory and compliance requirements for government payers, self-funded and commercial payers.
• Ensures appropriate and accurate information is entered into claims system for processing of payment.

Behavioral Health Utilization Management Clinician for Substance Abuse at Sentara Health

Behavioral Health Utilization Management Clinician, LCSW, LPC, LMFT, RN

Behavioral Health Utilization Management Clinician/LCSW/LPC/LMFT/RN for Substance Abuse at Sentara Health. Review clinical information to authorize services ensuring compliance with medical necessity criteria.

• Collaborate closely with physicians, nurses, social workers, and a wide range of medical and non-medical professionals to coordinate delivery of healthcare services
• Assess the member’s specific health plan benefits and the additional medical, community, or financial resources available
• Provide utilization management (UM) services which promote quality, cost-effective outcomes by helping member populations achieve effective utilization of healthcare services
• Facilitate outstanding member care using fiscally responsible strategies
• Collect and assess member information pertinent to member’s history, condition, and functional abilities in order to promote wellness, appropriate utilization, and cost-effective care and services
• Coordinate necessary resources to achieve member outcome goals and objectives
• Accurately document case notes and letters of explanation which may become part of legal records
• Perform concurrent review of members admitted to inpatient facilities, residential treatment centers, and partial hospitalization programs
• Maintain contact with the inpatient facility utilization review personnel to assure appropriateness of continued stay and level of care
• Identify cases that require discharge planning, including transfer to skilled nursing facilities, rehabilitation centers, residential, and outpatient to include behavioral health, home health, and hospice services while considering member co-morbid conditions
• Review referral and preauthorization requests for appropriateness of care within established evidence-based criteria sets
• When applicable, identify and negotiate with appropriate vendors to provide services
• When appropriate, negotiate discounts with non-contracted providers and/or refer such providers to Provider Network Department for contract development
• Work with multidisciplinary teams utilizing an integrated team-based approach to best support members

Utilization Management Clinician assessing member needs for optimal care delivery

Utilization Management Clinician – Tuesday - Saturday

Utilization Management Clinician collaborating with healthcare professionals to enhance member care and outcomes. Assessing health plan benefits and coordinating healthcare services with a focus on cost-effective solutions.

• Provide clinical review of services for members or enrollees with mental health, substance use, and/or developmental disabilities including diagnosis review, medical necessity criteria, determining member eligibility; level of care needed and making service authorization decisions regarding individual service authorizations with timely, clear, concise documentation.
• Provide clinical triage for members seeking services through Screening, Triage and Referral.
• Provide consultation and technical assistance to providers regarding clinical care needs, levels of care, Client Rights Rules, evidenced based practices, scope of practice issues etc.
• Provide ongoing review/staffing/consultation of treatment documentation of needs for members participating in group, family or individual services.

MH/SU UM Clinician providing clinical reviews for mental health and substance use services.

MH/SU UM Clinician

MH/SU UM Clinician providing clinical reviews and consultations regarding mental health, substance use, and developmental disabilities. Remote position within North Carolina with opportunities to make a tangible impact.

• Responsible for complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear
• Serves as a resource to lower-level clinicians and staff
• May collaborate with leadership to assist in process improvement initiatives to improve the efficiency and effectiveness of the utilization reviews within the medical management processes
• Assesses and applies medical policies and clinical guidelines within scope of licensure
• Conducts and may approve pre-certification, concurrent, retrospective, out of network and/or appropriateness of treatment setting reviews by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract
• May process a medical necessity denial determination made by a Medical Director
• Develops and fosters ongoing relationships with physicians, healthcare service providers and internal and external customers to help improve health outcomes for members
• Refers complex or unclear reviews to higher level nurses and/or Medical Directors
• Educates members about plan benefits and physicians
• Collaborates with leadership in enhancing training and orientation materials
• May complete quality audits and assist management with developing associated corrective action plans
• May assist leadership and other stakeholders on process improvement initiatives
• May help to train lower-level clinician staff

Medical Management Clinician Senior role at Elevance Health

Senior Medical Management Clinician

Medical Management Clinician Senior role focusing on complex cases at Elevance Health. Ensuring appropriate administration of plan benefits and collaborating with healthcare providers.

• Facilitate the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation
• Collect and assess patient information pertinent to patient’s history, condition, and functional abilities
• Develop a comprehensive, individualized care management plan
• Link clients with appropriate providers and resources throughout the continuum of health and human services and care settings
• Ensure that the care provided is safe, effective, client-centered, timely, efficient, and equitable
• Interact with other PacificSource personnel to assure quality customer service is provided
• Act as an internal resource by answering questions requiring medical or contract interpretation

Care Management Clinician improving client wellness and coordinating health services.

Care Management Clinician

Care Management Clinician improving client wellness and coordinating health services. Requires 3 years of clinical experience and active professional licensure in the US.

Clinician jobs in North Carolina