Clinical Utilization Review Specialist

2 days ago


Mirando City, Texas, United States Centene Corporation Full time
Job Title: Clinical Utilization Review Specialist

Join Centene Corporation, a leading healthcare company, as a Clinical Utilization Review Specialist. In this role, you will play a critical part in ensuring that our members receive high-quality, medically necessary care for mental health and substance abuse services.

Key Responsibilities:
  • Evaluate member treatment plans for mental health and substance abuse to ensure medical appropriateness
  • Perform prior authorization reviews for mental health and substance abuse services
  • Conduct concurrent reviews of behavioral health inpatient services to determine overall member health and treatment needs
  • Analyze behavioral health member data to improve quality and utilization of services
  • Provide education to providers, members, and their families on behavioral health utilization processes
  • Interact with behavioral health providers to discuss level of care and services
  • Collaborate with medical directors and leadership to improve care quality and efficiency
  • Develop and present cases in staffing and integrated rounds
Requirements:
  • Graduate of an accredited school of nursing or bachelor's degree
  • 2-4 years of related experience
  • License to practice independently and/or state-required licensure
  • Master's degree for behavioral health clinicians
  • Clinical knowledge and ability to review and assess treatment plans for mental health and substance abuse

Centene offers a comprehensive benefits package, including competitive pay, health insurance, 401K, and stock purchase plans. We value diversity and are an equal opportunity employer. Qualified applicants with arrest or conviction records will be considered in accordance with applicable law.



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