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Lead Utilization Review Clinician

3 months ago

Woodland Hills, California, United States Centene Corporation Full time

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.

*Must have clinical licensure in California or Texas.

Hours are 9:30am-6pm PST.

Position Purpose: Review / authorize utilization of mental health and substance use services across the continuum of levels of care. Serve as subject matter expert within in team/department. Provide oversight of team workload and direct cases to leaders or Medical Directors. Provide backup support to leaders in management or Health Plan meetings.

  • Reviews member's medical records and clinical information to determine if mental health and substance abuse services delivered are medically appropriate
  • Oversees the review of member's medical records from providers to determine if mental health and substance abuse services delivered are medically appropriate
  • Provides insight and guidance on the review of member medical records to the utilization review BH team
  • Provides guidance and expert knowledge as appropriate to the behavioral health utilization review team members to ensure the assessment of care determination is in accordance with policies, procedures and regulations
  • Evaluates and assesses the most complex member's care before, during, and after care of services to ensure level of care and services are medically appropriate related to mental health and substance abuse
  • Performs and manages the most 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 the most complex concurrent review of behavioral health (BH) services to determine overall health of member, treatment needs, and discharge planning
  • Provides subject matter expertise and insights around mental health and substance abuse for complex members based on prior experience and recommends improvements related to utilization review processes
  • Analyzes BH member data and identifies improvements regarding quality of care and services to BH members in accordance with policies, procedures, and regulations
  • Collaborates with BH healthcare providers as appropriate to discuss level of care and/or services and issues that have been identified
  • Partners with Medical Directors and leadership on opportunities to improve services through development of new processes and/or policies
  • Provides oversight of all utilization reviews due each day and manages outages but reassigning work to ensure compliance to timeliness standards
  • Helps People Leader to implement change by being a champion of change management. Fills in for People Leader as needed in team, Health Plan, or departmental meetings
  • Performs other duties as assigned
  • Complies with all policies and standards
Education/Experience: Requires Graduate of an Accredited School of Nursing or Bachelor's degree and 5 – 7 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.
Highly advanced 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.

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
Pay Range: $ $62.54 per hour

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.