Utilization Review Clinician - Behavioral Health

Centene Management Company LLC; New York (NY); Hybride; USD 37 000 - 67 000; Plein temps

Avantages offerts par ce poste

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off + holidays

Résumé du poste

Centene is seeking a licensed clinician to remotely perform clinical reviews and assess care for mental health and substance abuse. The role requires active licensure and strong knowledge of BH utilization review, with NY licensure preferred. Standard business hours apply Eastern Time, Monday through Friday.

Responsibilities include evaluating care levels, prior authorization reviews, concurrent inpatient review, and provider education. A master’s in behavioral health is preferred.

Qualifications

• Experience in mental health and substance abuse utilization review.
• Ability to assess treatment plans and care levels.
• Knowledge of regulatory guidelines for BH services.

Responsabilités

• Evaluates treatment for mental health and substance abuse to ensure medical appropriateness.
• Performs prior authorization reviews for BH services.
• Performs concurrent BH inpatient reviews and discharge planning.
• Analyzes BH data to improve quality and utilization.
• Provides education to providers, members and families regarding BH utilization.
• Interacts with BH providers and medical directors to improve care quality.

Connaissances

Mental health

Substance abuse

Clinical review

Prior authorization

Education and training

Formation

Bachelor's degree

Nursing license

Master’s degree in behavioral health

Description du poste

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 is a fully remote position requiring availability Monday through Friday from 8:30 a.m. to 5:00 p.m. Eastern Time. Candidates must hold an active, applicable clinical license, with New York State licensure strongly preferred.

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 graduation from an accredited school of nursing or a bachelor’s degree, along with 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

For Fidelis Care only: LMSW, LCSW, LMHC, LPC, LMFT, LMHP or RN required.

Pay Range

$27.02 - $48.55 per hour

Benefits and Compensation

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.

Company Culture

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 is committed to helping people live healthier lives. We provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well.

Equal Opportunity Employer

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.