Clinical Resource Manager

1 week ago


Boonton, New Jersey, United States St. Clare's - Boonton Full time
About the Role

At St. Clare's - Boonton, we are committed to delivering high-quality, patient-centered care. As a Behavioral Health Utilization Review Specialist, you will play a critical role in ensuring that our patients receive the necessary resources and support to achieve optimal outcomes.

Key Responsibilities
  • Conduct thorough reviews of patient medical records to determine medical necessity, intensity of service, and severity of illness.
  • Collaborate with external case managers and managed care organizations to secure pre-authorization, concurrent reviews, and appeals/denials management.
  • Assist the treatment planning team in understanding insurance requirements and complete UR audits for billing compliance.
  • Develop and implement strategies to facilitate quality, clinical, and cost-effective outcomes.
Requirements
  • Bachelor's degree in Social Work, Psychology, or a related field.
  • Knowledge of DSM 5 diagnosis and medical necessity criteria for behavioral health levels of care.
  • Knowledge of basic psychological and medical terminology.
Preferred Qualifications
  • Masters degree in Social Work, Psychology, or a related field.
  • One year of experience in direct care (inpatient or outpatient) mental health, case management, discharge planning, or nursing management.


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