Utilization Review Clinician - Behavioral Health (PIC)

Centene Corp.; Kentucky; Hybrid; USD 37.000 - 68.000; Vollzeit

Benefits dieser Stelle

competitive pay

health insurance

401K and stock purchase plans

tuition reimbursement

paid time off plus holidays

a flexible approach to work withRemote

Zusammenfassung

Centene Corp. seeks a remote behavioral health reviewer to support utilization management and quality improvement across mental health and substance use services. You will review cases, authorize care, and coach providers while coordinating with health plans and medical directors.

Strong licensure options (LCSW/LMHC/LCPC/LMFT/LMHP/RN) and experience in outpatient or residential settings are highly valued, with a focus on presenting findings to leadership and improving care efficiency.

Qualifikationen

• Graduate degree in nursing or related field with clinical focus.
• Active licensure to practice in applicable state.
• Experience with mental health and substance use utilization review.

Aufgaben

• Evaluates member’s mental health and substance use treatment for medical appropriateness.
• Performs prior authorization reviews for mental health and substance use.
• Performs concurrent BH inpatient reviews and discharge planning.
• Analyzes BH data to improve utilization and quality.
• Provides education to providers and families on BH utilization.
• Interacts with BH providers and leadership to discuss care levels.

Kenntnisse

Utilization management

Clinical record review

Provider coaching

Data presentation to leadership

Ausbildung

Bachelor's degree and 2–4 years related experience

Master’s degree in behavioral health (preferred)

Independent licensure (LCSW/LMHC/LCPC/LMFT/LMHP/RN)

Jobbeschreibung

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

• 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

Benefits

• competitive pay


• health insurance


• 401K and stock purchase plans


• tuition reimbursement


• paid time off plus holidays


• 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