Utilization Review Clinician - Behavioral Health

Centene Corporation; Kentucky; Remote; USD 56,000 - 101,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off + holidays

Remote/hybrid/office options

Job summary

Centene Corporation is seeking a remote Behavioral Health Utilization Review Specialist to assess care for mental health and substance use, reviewing authorization requests and inpatient cases across various settings. The role emphasizes collaboration with providers, medical directors, and care teams to ensure appropriate levels of care.

Qualified candidates typically hold nursing or behavioral health credentials and relevant licensure with 2–4 years of related experience.

Qualifications

• Requires RN/clinical licensure and behavioral health credentials.
• Experience reviewing mental health and substance use treatment plans.
• Knowledge of utilization review processes and regulatory guidelines.
• Prior experience with providers and healthcare teams.

Responsibilities

• Evaluates treatment for MH and SUD before, during, and after services.
• Performs prior authorization reviews to determine medical appropriateness.
• Performs concurrent BH inpatient reviews and discharge planning.
• Analyzes BH data to improve service utilization.
• Educates providers, members, and families on BH utilization.
• Interacts with BH providers to discuss level of care.
• Engages with medical directors to improve care quality and efficiency.
• Formulates and presents cases in staffing and rounds.
• Performs other duties as assigned and complies with policies.
• Meets licensure and regulatory requirements for role.

Skills

Clinical review

Prior authorization

BH utilization review

Education to providers

Collaboration with medical directors

Data interpretation

Education

Bachelor's degree

Master’s degree in behavioral health

Graduate of an Accredited School Nursing

LCSW

LMHC

LPC

LMFT

LMHP

RN State Licensure

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 Ambetter / Marketplace brand by reviewing behavioral health authorizations requests for the following settings: inpatient, residential treatment, and partial hospitalization. The schedule is Monday through Friday, 8-5 pm eastern or central. Preference will be given to applicants who reside in either central or eastern time zone United States and have prior utilization management or review experience.

• 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: $27.02 - $48.55 per hour
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.
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. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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