Utilization Review Clinician - Behavioral Health

Centene Management Company LLC; California (MO); Hybrid; USD 37,000 - 66,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Remote work options

Job summary

Centene Management Company LLC is seeking a remote clinical reviewer focused on mental health and substance use care to support the California Market, with a schedule of Monday through Friday, 9:00–18:00 or 9:30–18:00 Pacific Time, and occasional overtime. Applicants from other states may apply if they can align with Pacific Time.

The role requires nursing or bachelor's level education, 2–4 years of related experience, and licensure as applicable.

Qualifications

• Requires nursing degree or Bachelor's in a related field.
• 2–4 years of related clinical experience.
• License to practice independently per state requirements; multiple licenses listed.
• Master’s degree for behavioral health clinicians preferred.

Responsibilities

• Evaluates member’s treatment for mental health and substance use to ensure medically appropriate care.
• Performs prior authorization reviews for mental health and substance use.
• Performs concurrent BH inpatient reviews to assess health, needs, and discharge planning.
• Analyzes BH data to improve quality and utilization of services.
• Provides education to providers, members, and families on BH utilization processes.
• Interacts with BH providers and discusses level of care and services.
• Engages with medical directors to improve care quality and efficiency.
• Performs other duties as assigned.

Skills

Behavioral health utilization review

Regulatory guidelines knowledge

Prior authorization reviews

Education

Bachelor's degree in nursing

Master's degree in behavioral health

Job description

Position Purpose

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.

Key Details

This fully remote role supports the California Market. Open to applicants in other states if they are able to the work the schedule: Monday through Friday, 9-6 pm or 9:30am - 6pm pacific time zone (depending on lunch) with rotating holidays and occasional over time. Preference will be given to applicants with behavioral health and utilization management or review experience.

Responsibilities

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 regrading 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.

Education & Experience

Requires Graduate of an Accredited School Nursing or Bachelor's degree and 2 – 4 years of related experience. License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state required. Master’s degree for behavioral health clinicians required. Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse preferred. 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.

License / Certification

LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor 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.

Pay Range

Pay Range: $27.02 - $48.55 per hour

About Centene

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

Benefits

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.

Equal Opportunity Statement

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.