Remote Utilization Review Clinician- Behavioral Health

Centene

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Business Area: Clinical & Care Management
Job Type: Full time
Date Posted: Nov 14 2023
Job Number: 1475813

Description

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Job Description

THIS POSITION IS REMOTE/WORK FROM HOME. MUST HOLD A VALID LICENSURE IN THE STATE IN WHICH YOU RESIDE AND BE ABLE TO WORK CENTRAL TIME ZONE HOURS MONDAY-FRIDAY 8AM – 5PM WITH OCCASSIONAL AFTER HOURS, HOLIDAYS AND WEEKENDS. THIS ROLE IS ELIGIBLE FOR OVERTIME PAY.

Position Purpose: Perform duties to authorize and review utilization of mental health and substance abuse services provided in inpatient, outpatient and intermediate care settings, provide and/or review intakes and initial evaluations, brief focused treatment interventions, monitor quality of care, collect and analyze utilization and cost of care data, assist with discharge planning, arrange transportation; provide member assistance and participate in special utilization projects.

  • Authorize, direct and monitor care for mental health and substance abuse problems according to clinical information given by providers and internal criteria for medical necessity and appropriateness of care.
  • Ensure compliance with all performance measures in regards to appeals, denials, higher level of care admission certification and concurrent review timeliness, Outpatient Treatment Report review timeliness, readmissions, and others as indicated.
  • Interact with physicians and social workers for discharge planning.
  • Direct and coordinate follow-up to ensure plans for continuity of care and adherence to HEDIS standards.
  • Compile and report daily review activity and facility statistics.
  • Participate in quality improvement activities, supporting network development and interfacing with treatment facilities and the professional community.
  • Verify subscriber eligibility and existing benefits for mental health and substance treatment, prior to authorizing all levels of treatment including concurrent outpatient.
  • Track benefit usage and advise appropriate parties of exhaustion of benefits.
  • Interact with Medical Director or designee to discuss clinical authorization questions and concerns regarding specific cases.

Education/Experience: Master’s degree in Behavioral Health or RN. 3+ years experience in psychiatric and/or substance abuse health care settings including utilization review. Working knowledge of utilization review procedures, mental health and substance abuse community resources and network providers.

License/Certification: Required to have license to practice independently, and/or have obtained the state required licensure as outlined by the applicable state. This includes but is not limited to licenses such as LPC, LCSW, LMFT, LMHC, LIMHP, and RN.

Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

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.