Senior Utilization Review Clinician - Behavioral Health

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.
 

Position Purpose: Performs 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, including addressing issues related to quality of care issues. Handles clinical cases, workflows, and tasks with increased complexity.

• Reviews member’s medical records from providers via written transmission or phone discussions to determine if mental health and substance abuse services delivered are medically appropriate

• Evaluates and assesses complex member treatment related to mental health and substance abuse before, during, and after services to ensure level of care and services are medically appropriate

• Performs and manages complex prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria

• Performs and manages some complex concurrent review of behavioral health (BH) services to determine overall health of member, treatment needs, and discharge planning

• Identifies process improvements opportunities related to BH utilization review processes to improve quality of care services to BH members and develop efficiencies in accordance with policies, procedures, and regulations

• Identifies quality of care issues and potential fraud, waste and abuse activities related to mental health and substance abuse

• Collaborates with BH healthcare providers as appropriate to discuss level of care and/or services and issues that have been identified

• Functions as a team Subject Matter Expert on workflows and conducts training for new hires

• Engages with medical directors and leadership to improve the quality and efficiency of care

• Formulates and presents cases in staffing and integrated rounds

• Provides education to providers regrading BH utilization process

• Performs other duties as assigned

• Complies with all policies and standards

Education/Experience: Requires Bachelor's degree and 4 – 6 years of related experience. License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state required.

License/Certification:

• LCSW- License Clinical Social Worker required or

• LMHC-Licensed Mental Health Counselor required or

• LPC-Licensed Professional Counselor required or

• Licensed Mental Health Professional (LMHP) 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