Behavioral Health UM Reviewer (Licensed)-Remote-NC

About the Role

This position will evaluate medical necessity, appropriateness, and efficiency of the services requested for authorization against established criteria adopted by the LME/MCO.

Responsibilities

• Respond to all requests for authorizations from the provider community with appropriate authorization decisions guided by medical necessity and clinical guidelines.
• Authorize services based on individual need and standardized procedures.
• Review and authorize initial requests, concurrent requests, urgent requests, and retrospective requests.
• Consult with providers regarding authorization requests.
• Consult with Partners BHM physician regarding requests involving questions about authorization, enrollee health and safety, medication issues, lack of response to services, and need for Peer Review when the MHSU Utilization Management Reviewer cannot approve the request.
• Develop letters communicating to enrollees and providers the reason for any adverse decision and provide information regarding appeal options.

Requirements

• Comprehensive knowledge of mental illness and appropriate treatment for major diagnostic categories, behavioral health principles, techniques, and practices.
• Considerable knowledge of person-centered and recovery philosophies and interventions.
• Considerable knowledge of assessments and interventions for mental health, developmental disability, and substance use disorders.
• Knowledge of the 1915 (b) (c) waiver.
• Knowledge of psychiatric medications and side effects.
• Knowledge of evidence-based practices.
• Awareness of cultural diversity.
• Excellent computer skills, including proficiency in Microsoft Office products (Word, Excel, Outlook, etc.).
• Ability to engage providers in collegial discussions about plans of care and best clinical practices.
• Ability to establish and maintain effective working relationships with consumers, their families, and stakeholders (civic, legal, medical, social, religious).
• Ability to express ideas clearly and concisely orally and in writing, and to plan and execute work effectively and efficiently.
• Ability to utilize complex telephone and computer systems, and to read and document information electronically.
• Ability to make prompt decisions based on relevant facts.
• Detail-oriented, able to independently organize multiple tasks and priorities, and manage an assigned caseload under pressure of deadlines.

Qualifications

• A Master’s Degree in a Human Services field with clinical licensure and two (2) years of post-Master’s experience in behavioral health; or a Registered Nurse with two (2) years of experience in behavioral health, post RN degree.
• Must reside in North Carolina.
• Current unrestricted license with the appropriate professional board of licensure in the state of North Carolina (e.g., Registered Nurse licensed by the N.C. Board of Nursing, or Independent License in NC as a LCSW, LCMHC, LPA, LMFT). An Associate license does not meet the requirements. Dual licensure (e.g., one specialty listed here plus LCAS) is acceptable, but LCAS alone does not meet NC DMA contract requirements.
• Employee is responsible for complying with respective licensure board’s continuing education/training requirements to maintain an active license.

Benefits

• Annual incentive bonus plan.
• Medical, dental, and vision insurance with low deductible/low cost health plan.
• Generous vacation and sick time accrual.
• 12 paid holidays.
• State Retirement (pension plan).
• 401(k) Plan with employer match.
• Company-paid life and disability insurance.
• Wellness Programs.
• Public Service Loan Forgiveness Qualifying Employer.

Pay

Projected hiring range: Depending on experience.

Schedule

• Sunday–Thursday (8-hour shifts).
• Shift options: 8:00 AM–5:00 PM or 8:30 AM–5:30 PM.

Location

Remote option in NC; available for any of Partners' locations.