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.
 

Required Work Schedule: Wednesday - Saturday (Set Schedule)

NOTE: Position requires working EVERY Saturday and rotating holidays

Full-time Flexible Hours: 4 days, 10 hours shifts (40 hrs per week)

Must be able to work Central Time Zone hours

NOTE: Must be fully licensed for the state of Texas via the Texas BHEC if you hold a LPC, LCSW, or LMFT. Registered Nurse can hold Texas State Licensure and/or Compact State Licensure.

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:

• Requires Graduate of an Accredited School Nursing or Bachelor's degree and 2 – 4 years of related behavioral health or substance abuse or ASAM experience. OR
• Master’s degree for behavioral health clinicians is required and license and 2 - 4 years of related behavioral health and/or substance abuse addiction disorders experience is preferred.
• Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse is preferred.
• Knowledge of mental health and substance abuse utilization review process is preferred.
• Experience working with providers and healthcare teams to review care services related to mental health and substance abuse is preferred.
• Utilization Review/ Utilization management with behavioral health cases
• Precertification, Concurrent Review, Discharge reviews for behavioral health
• Direct in patient Behavioral Health and SUD inpatient hospital experience
• Managed care knowledge is preferred
• Working knowledge and experience with the ASAM Criteria and levels of care for Addiction Treatment is preferred
• Direct BH/SUD inpatient intake assessments experience is preferred
• Direct work experience in In-Patient Behavioral Health Units, Partial Hospitalization, or Residential Treatment is required

License/Certification:

• LCSW- License Clinical Social Worker required or
• LMHC-Licensed Mental Health Counselor required or
• LPC-Licensed Professional Counselor required or
• Licensed Marital and Family Therapist (LMFT) required or
• Licensed Mental Health Professional (LMHP) 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.  Total compensation may also include additional forms of incentives.

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