Utilization Review Clinician - Behavioral Health
About the role
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 to ensure level of care and services are medically appropriate.
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.
Complies with all policies and standards.
Responsibilities
- Performs a clinical review and assesses care related to mental health and substance abuse.
- Makes determinations about the appropriateness of level of care and services related to mental health and substance abuse.
- Evaluates member’s treatment for mental health and substance abuse before, during, and after services to ensure level of care and services are medically appropriate.
- Reviews prior authorization requests for mental health and substance abuse services to ensure they meet regulatory guidelines and criteria.
- Conducts concurrent reviews of inpatient behavioral health cases to assess the overall health of the member, treatment needs, and discharge planning.
- Analyzes member data to enhance the quality and appropriate utilization of services.
- Shares educational materials with providers, members, and their families regarding the utilization process for mental health and substance abuse services.
- Collaborates with healthcare providers to discuss the appropriateness of level of care and services.
- Communicates with medical directors and leadership to identify areas for improvement in care delivery.
- Presents cases in staffing and integrated rounds to facilitate discussions and decision-making.
- Completes other tasks as assigned.
Requirements
- Must be licensed in the state of Georgia.
- Must be willing to work an occasional weekend shift.
- Must reside in an EST or CST time zone.
Qualifications
- Requires 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.
- 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 - License Clinical Social Worker required or
- Licensed Mental Health Counselor (LMHC) required or
- Licensed Professional Counselor (LPC) required or
- Licensed Marital and Family Therapist (LMFT) required or
- Licensed Mental Health Professional (LMHP) required or
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required.
Skills
- Strong clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse.
- Understanding 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
- Competitive pay
- Health insurance
- 401K and stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- A flexible approach to work with remote, hybrid, field or office work schedules.