Clinical Care Reviewer II - Behavioral Health

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

Job Summary

Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services) and care coordination for members.

Essential Functions

• Complete prospective, concurrent and retrospective review of Behavioral Health services
• Identify, document, communication and coordinate care engaging collaborative care partners to facilitation transition to an appropriate level of care
• Engage with medical director when additional clinical expertise if 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
• Provide guidance 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.

Education and Experience

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

Competencies, Knowledge and 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, 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) required
• MCG Certification is required or must be obtained within six (6) months of hire required

Working Conditions

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

Compensation Range

$62,700.00 - $100,400.00

Compensation Type (hourly/salary)

Hourly

Organization Level Competencies

• Fostering a Collaborative Workplace Culture
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.