Behavioral Health UR Clinician

Independent Health; United States; Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization is seeking a Behavioral Health Utilization Review Clinician responsible for managing behavioral health benefits. The role involves conducting clinical reviews, collaborating with providers, and ensuring compliance with standards. Ideal candidates will have relevant licenses and experience in behavioral health settings.

Benefits

Full range of benefits

Generous paid time off

Scorecard incentive

Qualifications

• Two years of experience in behavioral health clinical settings required.
• Experience in managed care and utilization management preferred.

Responsibilities

• Manage behavioral health benefits through utilization management functions.
• Perform clinical reviews and consultations for members' health conditions.

Skills

Interpersonal Skills

Problem Solving

Communication

Education

Masters level licensed behavioral health professional

Registered Nurse (RN)

Tools

MS Excel

MS Access

Job description

FIND YOUR FUTURE

We're excited about the potential people bring to our organization. You can grow your career here while enjoying first-class perks, benefits and a culture that fosters growth, innovation and collaboration.

Overview

The Behavioral Health Utilization Review Clinician will primarily be responsible for managing behavioral health benefits through utilization management functions as well as case management activities.

Qualifications

• Masters level licensed behavioral health professional (such as a LCSW, LMSW, LMHC, LPC, LMFT) or a Registered Nurse (RN) with active, unrestricted NYS license required.
• Two (2) years of experience in a behavioral health clinical, managed care, and/or care coordination setting required.
• Experience in a health plan/managed care setting, utilization management, case management, and/or quality improvement activities preferred.
• Certified Case Manager (CCM) preferred.
• Excellent knowledge base of community resources and roles of various community agencies.
• Ability to work in the community at identified high volume facilities/providers in addition to the office/home setting.
• Excellent interpersonal, verbal, and written communication skills.
• Creativity, self-motivation, flexibility, and effective problem-solving skills.
• Ability to use MS Excel or Access for data collection and to analyze data, assess outcome measurements, and intervene appropriately is preferred.
• Experience using clinical review criteria.
• Self-starter with high level of accountability and responsibility.
• Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable.

Essential Accountabilities

• Perform benefit management tasks within regulatory time frames: collecting and documenting demographic and clinical information needed to conduct medical necessity review; accessing appropriate and established clinical criteria; talking to requesting provider(s) as needed; rendering medical necessity decision; and preparing request for review by assigned medical director, as needed.
• Perform utilization of behavioral health (BH) services for members, ensuring compliance with internal and external standards set by regulatory and accreditation entities.
• Refer appropriate cases to the Medical Director for review and work closely with Case Management to address member needs.
• Perform pre-service clinical consultations, concurrent and post-service clinical reviews to determine the appropriateness of services requested for the diagnosis and treatment of members’ health conditions, applying established clinical review criteria, guidelines and medical policies and contractual benefits as well as State and Federal Mandates.
• Perform clinical review telephonically, electronically, or on-site, depending on customer and departmental needs.
• Plan, implement, and document utilization management activities and processes.
• Ensure compliance with corporate and departmental policy and procedure, identify, and refer potential quality of care and utilization issues to Medical Director.
• Identify eligible insured individuals from available data set(s); enroll in applicable CM program; actively engage insured individual in CM program to achieve measurable CM goals; and discharge from CM program when appropriate.
• Conduct assessments to identify individual needs and develops person centered care plans with goals and interventions. Monitors and evaluates effectiveness of care plan and modifies plan as needed.
• Utilize appropriate communication techniques with members and providers to obtain clinical information, assess medical necessity of services, advocate for members in obtaining needed services as appropriate, and interact with the treating physician or other providers of care.
• Assist hospital/facility discharge planners to coordinate post inpatient BH treatment for continuity of care.
• Accurately and consistently interpret required clinical criteria, medical policy, contract benefits, and State and Federal Mandates.
• Maintain compliance with all regulatory and accrediting standards.
• Assist with training and special projects, as assigned.
• Monitor and evaluate effectiveness of care plan and modify plan as needed.
• Collaborate with internal and external resources, providers, and community agencies to meet identified needs of the members.
• Review policies, standard operating procedure (SOP) documents, reports and data related to BH CM programs.
• Assist with the preparation of the annual program evaluations and Work Plans for the BH UM and/or CM Programs.
• Aid department efforts with quality improvement activities through data collection, measurement, reporting, evaluation, and evidence-based intervention development related to BH benefits and/or BH specialty providers.
• Participate in identification, analysis and evaluation of quantitative and qualitative CM program outcomes and recommend interventions for improvement and implement recommendations when appropriate .

Immigration or work visa sponsorship will not be provided for this position

Hiring Compensation Range: $33.50 - $38.00 hourly

Compensation may vary based on factors including but not limited to skills, education, location and experience.

In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.

As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. Click here for additional EEO/AAP or Reasonable Accommodation information.

Current Associates must apply internally via the Job Hub app.