About this role

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 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

Graduate of an Accredited School Nursing or Bachelor's degree
2 – 4 years of related experience
License to practice independently
LCSW, LMHC, LPC, LMFT, LMHP required
RN
Registered Nurse
State Licensure and/or Compact State Licensure 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

Utilization Review Clinician – Behavioral Health

Key skills