Utilization Management - Behavioral Health (Remote)
Location: Remote (Preferred locations: FL, GA, KY, MI, NY, OH, WI)
Work Hours: 8:00 AM – 5:00 PM EST
Compensation: $40.00 per hour
Employment Type: Temp-to-Perm, Full-Time

Job Summary

A managed care organization is seeking a Care Review Clinician I to join the Utilization Management - Behavioral Health team. This role is responsible for reviewing provider submissions for prior service authorizations and assessing medical necessity. The clinician will be integral in ensuring members receive appropriate care while maintaining compliance with state and federal guidelines.

Key Responsibilities

• Conduct concurrent reviews and prior authorization assessments following company policies.
• Determine appropriate benefits, eligibility, and expected length of stay for requested services.
• Collaborate with interdepartmental teams to enhance continuity of care for members, including behavioral health and long-term care.
• Maintain productivity and quality standards.
• Participate in staff meetings and mentoring activities for new team members.
• Build and maintain relationships with providers and internal/external customers.
• Consult with medical directors as needed for complex cases.
• Ensure compliance with workplace safety standards and HIPAA regulations.

Required Qualifications

• Education: Completion of an accredited nursing program (a combination of education and experience will be considered in lieu of a nursing degree).
• Experience: 0-2 years of clinical practice, preferably in hospital nursing, utilization management, or case management.
• Licensure: Active, unrestricted RN, LPN, LCSW, or LPC license in any state.

Preferred Qualifications

• Background in behavioral health services and/or experience in utilization management within a managed care organization.
• Knowledge of state and federal regulations related to utilization management.
• Familiarity with InterQual and other medical necessity determination tools.
• Experience with NCQA standards.

Skills & Competencies

• Strong problem-solving and communication skills.
• Ability to manage multiple priorities independently.
• Proficiency in Microsoft Office Suite.
• Ability to work effectively within a remote team environment.
• High attention to detail and ability to follow established processes.