Clinical Care Reviewer II - Behavioral Health - Must be MA Licensed

About the role

Clinical Care Reviewer II – Behavioral Health processes medical necessity reviews for appropriateness of authorization for behavioral health care services, assists with discharge planning activities (e.g., outpatient services, home health services), and coordinates care for members.

Responsibilities

• Complete prospective, concurrent, and retrospective review of Behavioral Health services.
• Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transition to an appropriate level of care.
• Engage with medical director when additional clinical expertise is needed.
• Maintain knowledge of state and federal regulations, including State Contracts and Provider Agreements, benefits, and accreditation standards.
• Identify and refer quality issues to Quality Improvement.
• Identify and refer appropriate members for Care Management.
• Provide guidance to non-clinical staff and support to LPN staff.
• Attend medical advisement and State Hearing meetings, as requested.
• Assist Team Leader with special projects or research, as requested.
• Perform any other job-related duties as requested.

Requirements

• Associate of Science (A.S) in Nursing or Bachelor of Science (B.S) in Social Work or Master's degree in a mental health-related field (Psychology, Counseling Psychology, Marriage or Family Therapy).
• Three (3) years of clinical experience.
• Utilization Management/Utilization Review experience preferred.
• Medicaid/Medicare/Commercial experience preferred.

Skills

• Proficient data entry skills and ability to navigate clinical platforms successfully.
• Working knowledge of Microsoft Outlook, Word, and Excel.
• Effective oral and written communication skills.
• Ability to work independently and within a team environment.
• Attention to detail.
• Proper grammar usage and phone etiquette.
• Time management and prioritization skills.
• Customer service oriented.
• Decision making/problem solving skills.
• Strong organizational skills.
• Change resiliency.

Licensure and Certification

• Current, unrestricted Registered Nurse (RN) Licensure, or Licensed Social Worker (LSW), Licensed Clinical Social Worker (LCSW), Licensed Independent Clinical Social Worker (LICSW), Associate Clinical Social Worker (ACSW), Licensed Mental Health Counselor (LMHC), Licensed Professional Counselor (LPC), Licensed Marriage & Family Therapist (LMFT), or Licensed Mental Health Practitioner (LMHP).
• MCG Certification is required or must be obtained within six (6) months of hire.

Working Conditions

• General office environment; may be required to sit or stand for extended periods of time.
• Travel is not typically required.

Pay

$62,700.00 - $100,400.00. CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance.

Benefits

We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.