About the position
As a Utilization Review Clinician specializing in Behavioral Health at Centene, you will play a crucial role in ensuring that our members receive the appropriate level of care for their mental health and substance abuse needs. This position involves performing clinical reviews and assessments related to mental health and substance abuse, monitoring the appropriateness of care and services provided to our members. You will evaluate treatment plans before, during, and after services to ensure they meet medical appropriateness standards. Your responsibilities will include conducting prior authorization reviews to determine the medical necessity of services in accordance with regulatory guidelines. You will also perform concurrent reviews of behavioral health inpatient cases to assess the overall health of members, their treatment needs, and assist in discharge planning. Analyzing behavioral health member data will be essential to improve the quality and appropriate utilization of services. In this role, you will provide education to healthcare providers, members, and their families regarding the behavioral health utilization process. You will interact with behavioral health providers to discuss levels of care and services, and engage with medical directors and leadership to enhance the quality and efficiency of care. Additionally, you will be responsible for formulating and presenting cases during staffing and integrated rounds, and performing other duties as assigned while complying with all relevant policies and standards.
Responsibilities
- Perform clinical reviews and assess care related to mental health and substance abuse.
- Monitor and determine if the level of care and services are medically appropriate.
- Evaluate member's treatment for mental health and substance abuse before, during, and after services.
- Conduct prior authorization reviews related to mental health and substance abuse.
- Perform concurrent reviews of behavioral health inpatient cases.
- Analyze behavioral health member data to improve quality and appropriate utilization of services.
- Provide education to providers, members, and their families regarding behavioral health utilization processes.
- Interact with behavioral health healthcare providers to discuss levels of care and services.
- Engage with medical directors and leadership to improve 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.
Requirements
- Graduate of an Accredited School of Nursing or Bachelor's degree with 2-4 years of related experience.
- Master's degree for behavioral health clinicians required.
- License to practice independently as required by state regulations.
- 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.
- LCSW, LMHC, LPC, LMFT, LMHP, or RN state licensure 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 process.
- Experience working with providers and healthcare teams to review care services related to mental health and substance abuse.
Benefits
- 401(k)
- Health insurance
- Paid holidays
- Paid time off
- Tuition reimbursement
