Clinical Review Specialist
2 weeks ago
Join Centene Corporation, a leading healthcare company, as a Clinical Review Specialist. In this role, you will play a critical part in ensuring the quality and appropriateness of mental health and substance abuse services for our 28 million members.
Job Summary:We are seeking a highly skilled Clinical Review Specialist to perform clinical reviews and assessments of care related to mental health and substance abuse. As a key member of our Medical Management/Health Services team, you will monitor and determine if the level of care and services are medically appropriate.
Key Responsibilities:- Evaluate member treatment for mental health and substance abuse before, during, and after services to ensure medical appropriateness.
- Perform prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria.
- Conduct concurrent reviews of behavioral health inpatient services to determine overall member health, treatment needs, and discharge planning.
- Analyze behavioral health member data to improve quality and appropriate utilization of services.
- Provide education to providers, members, and their families regarding behavioral health utilization processes.
- Interact with behavioral health healthcare providers to discuss level of care and/or services.
- Engage with medical directors and leadership to improve the quality and efficiency of care.
- Formulate and present cases in staffing and integrated rounds.
- Perform other duties as assigned.
- Graduate of an accredited school of 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.
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.
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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