Behavioral Health Services Utilization Reviewer
2 weeks ago
This role is essential in coordinating, integrating, and monitoring the utilization of behavioral health services for members. You will ensure compliance with both internal and external standards set by regulatory and accreditation entities. Additionally, you will refer cases to the Medical Director for necessary reviews and work closely with Case Management to address members' needs. This position may require participating in a rotating on-call schedule to meet departmental timelines and possibly working additional hours as needed.
Key Responsibilities:
Level I: Conduct pre-service, concurrent, and post-service clinical reviews to assess the appropriateness of requested services based on members' behavioral health conditions. Utilize established clinical criteria, guidelines, and medical policies to ensure compliance with relevant mandates. Collaborate with providers to advocate for members and maintain quality care.
Engage in communication with members and providers to gather clinical information and assess the medical necessity of services. Interpret clinical criteria, medical policy, and benefits accurately while ensuring adherence to regulatory standards. Stay updated on changes and assist with training and special projects as assigned.
Level II: In addition to Level I duties, you will contribute process improvement ideas and resolve more complex issues. Mentor staff, lead initiatives, and participate in committees to enhance member and community health.
Level III: As a leader in the department, you will recommend new processes for efficiency and provide expert guidance on escalated issues. Mentor colleagues, assist in training, and support the Medical Director with various projects.
Minimum Qualifications:
Active NYS RN license with three years of behavioral health experience; or LMSW; or LCSW; or LMHC. A minimum of three years clinical experience is required, preferably in Utilization Management. Proficiency in Microsoft Office and a solid understanding of coding standards are essential. Strong written and verbal communication skills, multitasking abilities, and the capacity to work independently are also required.
Level II: Requires at least two years of experience in a utilization management role with the ability to take on broader responsibilities.
Level III: Requires a minimum of five years in a utilization management position or as a subject matter expert, with demonstrated leadership and training abilities.
Physical Requirements:
Must be able to travel within regions and work on a computer for extended periods.
Compensation Range:
Level I: Minimum $60,410 - Maximum $96,081
Level II: Minimum $60,410 - Maximum $106,929
Level III: Minimum $65,346 - Maximum $117,622
This salary range is subject to variation based on budget availability, prior experience, knowledge, and qualifications. Apart from salary, the total rewards package includes health/dental insurance, retirement plans, wellness programs, paid time off, and holidays.
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