Utilization Review Clinician - Behavioral Health

Centene Corporation; WaKeeney (KS); On-site; USD 37,000 - 67,000; Full time

Benefits offered by this job

Remote work

Competitive benefits

401K

Tuition reimbursement

Paid time off

Job summary

Centene Corporation is seeking a remote BH utilization reviewer to assess mental health and substance abuse care, authorize services, and present findings to health plan leadership. The role involves coordinating with providers, medical directors, and leadership to improve quality and efficiency of care.

The candidate should have a nursing or related bachelor’s degree with 2–4 years of experience and an applicable license. A master’s in behavioral health is preferred.

Qualifications

• Requires graduate of an accredited nursing school or bachelor's degree with 2–4 years of related experience.
• License to practice independently or state licensure as required.
• Master’s degree in behavioral health is required for clinicians.

Responsibilities

• conducts clinical reviews of mental health and substance abuse care to ensure medical appropriateness
• performs prior authorization reviews for BH services according to guidelines
• performs concurrent BH inpatient reviews and discharge planning
• analyzes BH data to improve quality and utilization of services
• provides education to providers and families about BH utilization
• interacts with BH providers and discusses level of care
• engages with medical directors to improve care quality and efficiency
• forms and presents cases in staffing and rounds
• performs other duties as assigned
• complies with all policies and standards

Skills

Clinical review

Utilization review

Provider coaching

Communication with leadership

Education

Bachelor's degree

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 with “Partnerships In Care” supports utilization management and quality improvement efforts by identifying outlier provider performance, conducting comprehensive clinical record reviews, and delivering individualized coaching to providers. The position also synthesizes findings into clear, actionable presentations for providers and health plan leadership. The Schedule is Monday through Friday 8-5 PM eastern, central, mountain, or pacific time zone. Preference will be given to applicants with (1) fully independent behavioral health social work, counseling, or therapy licenses (e.g. LCSW, LMHC, LCPC, LMFT), (2) experience in various mental health settings especially outpatient and residential treatment services, (3) utilization management / review, as well as (4) experience presenting to leadership/providers and advising providers on performance.

• 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