[Hiring] Utilization Review Clinician @Centene Corporation

Role Description

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.

• This is a fully remote position requiring availability Monday through Friday from 8:30 a.m. to 5:00 p.m. Eastern Time.
• Candidates must hold an active, applicable clinical license, with New York State licensure strongly preferred.
• 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 regarding 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.

Qualifications

• Requires graduation from an accredited school of nursing or a bachelor’s degree, along with 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.

Requirements

• For Fidelis Care only: LMSW, LCSW, LMHC, LPC, LMFT, LMHP or RN required.

Benefits

• Competitive pay.
• Health insurance.
• 401K and stock purchase plans.
• Tuition reimbursement.
• Paid time off plus holidays.
• 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.