Remote Behavioral Health, Clinical Care UM Review, After Hours, RN

AmeriHealth Caritas

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Dublin, Ohio, 43017 Category Behavioral Health Job Id 29348 Remote

Under the direction of the Supervisor, the After-Hours Behavioral Health Utilization Management Reviewer is responsible for assisting members with appropriate specialized behavioral health care coordination and care management services by completing medical necessity reviews.; Using clinical knowledge and experience, the BH UM Reviewer reviews the provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the BH UM Reviewer’s discretion to retain requests for additional information and/or request clarification.

The BH UM Reviewer will facilitate his/her professional judgment to evaluate the request and ensure that services are appropriately approved. Recognize care coordination opportunities and refer those cases to Integrated Health Care Management as needed.;; The BH UM Reviewer will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when indicated. Ensure that treatment delivered is appropriate and meets the Member’s needs in the least restrictive, least intrusive manner possible. The BH UM Reviewer will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational business units and uses clinical judgment in their application.

Education/ Experience:;

  • Required days to work:;
    • 8 or 10 hr shift: Monday, Tuesday, Saturday with either Wednesday or a Thursday or both depending hours (8s, 10s).;
    • 12 hr shift: Monday, Tuesday, Wednesday, Saturday **noting shifts crossover into 3rd shift, i.e. next day.;
  • Current and unrestricted Registered Nurse licensure. Will be required to obtain licensure in DC, LA, NC, and OH.
  • Registered Nurse candidates must be a graduate from an accredited institution with an Associate Degree or Bachelor’s Degree. Master’s Degree preferred. Must have OH or compact state Registered Nurse licensure.
  • Current and unrestricted LCSW, LMSW, LPC or LMFT licensure in OH. Will be required to obtain licensure in DC, LA, and NC. Master’s Degree from an accredited institution in social work/mental health. Must have completed a supervised field experience in case management, health or behavioral health as part of the degree requirements.
  • Minimum of 3 years of behavioral health and substance use disorder experience required.
  • Managed care and Utilization Management experience required.