Utilization Review Clinician

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.
 

Behavioral Health UR Clinical Call Center Environment - Coverage: 365/24 -7

Work Schedule: Monday - Friday: 9:00 am - 6:00 pm (CST)

Applicants MUST be physically based in Texas and fully licensed for TX

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.

• 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:

• License to practice independently and have obtained the state required licensure as outlined by the applicable state is required

• Requires Graduate of an Accredited School Nursing or Bachelor's degree and 2 – 4 years of related experience.

• Requires Graduate of an Accredited Master's degree - Behavioral Health related field is preferred

• Master's degree AND 2 - 4 years of related behavioral health and/or substance abuse addiction disorders experience is required.

• Direct experience with Utilization Review or Utilization Management related to Behavioral Health case is preferred

• Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse is preferred.

• Experience working with providers and healthcare teams to review care services, precertification, concurrent review, discharge reviews for mental health and substance abuse cases are preferred.

• Direct IOP Behavioral Health and/or SUD inpatient hospital experience is preferred

• Experience in Behavioral Health Case Management or Utilization Management in Managed Care Organizations, In-Patient Behavioral Health Units, Partial Hospitalization, or Residential Treatment is preferred

License/Certification:

• LCSW - License Clinical Social Worker required or

• LPC- Licensed Professional Counselor required or

• LMFT - Licensed Marital and Family Therapist required or

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required

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