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Clinical Utilization Specialist

1 month ago

Austin, Texas, United States Centene Corporation Full time

Job Summary:

We are seeking a skilled Clinical Utilization Specialist to join our Medical Management/Health Services team. As a key member of our team, you will play a critical role in ensuring the quality and appropriateness of care for our members.

Key Responsibilities:

  • Perform clinical reviews and assessments of care related to mental health and substance abuse
  • Monitor and determine if level of care and services related to mental health and substance abuse are medically appropriate
  • Evaluate member's treatment for mental health and substance abuse before, during, and after services to ensure level of care and services are medically appropriate
  • Perform prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria
  • Conduct concurrent review of behavioral health inpatient to determine overall health of member, treatment needs, and discharge planning
  • Analyze BH member data to improve quality and appropriate utilization of services
  • Provide education to providers, members, and their families regarding BH utilization process
  • Interact with BH healthcare providers as appropriate 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

Requirements:

  • 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

Benefits:

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.

Equal Opportunity Employer:

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