Behavioral Health Care Reviewer II - Care Coordination

CareSource; Massachusetts; Hybrid; USD 63,000 - 100,000; Full time

Job summary

CareSource in the United States is seeking a Clinical Care Reviewer II – Behavioral Health responsible for processing medical necessity reviews for authorization, assisting discharge planning (outpatient/home health) and coordinating care for members.

This role requires an RN or social work degree with at least 3 years of clinical experience, and knowledge of state/federal regulations. Collaboration with medical directors and guidance to staff are key expectations.

Qualifications

• RN licensure or social work degree with relevant experience.
• At least 3 years of clinical experience in behavioral health.
• Utilization Management/Utilization Review experience preferred.
• Knowledge of Medicaid/Medicare/Commercial programs preferred.

Responsibilities

• Complete prospective, concurrent and retrospective review of Behavioral Health services.
• Coordinate care engaging partners to facilitate transition to appropriate level of care.
• Engage with medical director when additional clinical expertise is needed.
• Maintain knowledge of state and federal regulations, benefits and accreditation standards.
• Identify quality issues and refer to Quality Improvement.
• Provide guidance to staff and participate in special projects.

Skills

Data entry

Microsoft Outlook

Microsoft Word

Microsoft Excel

Communication skills

Time management

Attention to detail

Team collaboration

Problem solving

Organization

Education

Associates of Science (A.S) in Nursing

Bachelor of Science (B.S) in Social Work

Master's degree in a mental health related field

Tools

Microsoft Outlook

Microsoft Word

Microsoft Excel

Job description

CareSource in the United States is seeking a Clinical Care Reviewer II – Behavioral Health responsible for processing medical necessity reviews for authorization, assisting discharge planning (outpatient/home health) and coordinating care for members.

This role requires an RN or social work degree with at least 3 years of clinical experience, and knowledge of state/federal regulations. Collaboration with medical directors and guidance to staff are key expectations.