Utilization Review Clinician

1 month ago

Tallahassee, 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.

THERE ARE 3 POSITIONS AVAILABLE/BUILDING A NEW PROGRAM.

THESE POSITIONS ARE REMOTE. QUALIFIED APPLICANTS WILL RESIDE IN THE STATE OF FLORIDA, AND THE WORK SCHEDULE IS MONDAY-FRIDAY, 8AM - 5PM; NO HOLIDAYS, NO ON-CALL, NO WEEKENDS.

THESE ROLES WILL BE SUPPORTING BEHAVIORAL HEALTH UTILIZATION MANAGEMENT FOR MEDICAID.

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

ADDITIONAL RESPONSIBILITIES FOR THIS NEW PROGRAM:

The UM role will be focusing on outlier management review of provider records with an overall objective of:

  • Helping facilities to improve documentation

  • Appropriate application of medical necessity

  • Adherence to billing guidelines

Beyond the regular responsibilities listed above, the role will:

  • Review full medical records submitted by the facilities evaluating strengths/opportunities in their assessments, TX planning, and case notes

  • Validate time billed aligns with documentation in the records

  • Ensure providers are moving members through treatment to promote recovery and resiliency and addressing SDoH needs

  • Compile all findings into a Clinical Summary that is concisely documented

  • Develop collaborative relationships with facilities engaged in the program and provide findings and develop performance improvement plan

  • Partner with the Health Plan leaders on outcomes, as well as SIU if FWA activities are identified

Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 2 – 4 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.

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: $25.97 - $46.68 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.

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