Utilization Review Clinician - Behavioral Health

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: Centene is seeking a remote Utilization Review Clinician – Behavioral Health to support our inpatient and outpatient Behavioral Health Medicare Plan. In this role, you will perform medical necessity reviews and authorization determinations to help ensure members receive appropriate, high-quality behavioral health services.

Behavioral health and/or utilization management experience is preferred, along with strong knowledge of medical necessity criteria and managed care principles.

• 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

Schedule: Monday–Friday, 8:00 AM–5:00 PM EST

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

Originally posted on Himalayas