Behavioral Health UM Reviewer – Adult Team

This is a fully remote position, open to applicants in North Carolina.

📋 Description

• Assess the medical necessity, appropriateness, and efficiency of requested services in accordance with established LME/MCO criteria.

• Address provider authorization requests with well-informed decisions, guided by medical necessity and clinical guidelines.

• Approve services based on individual requirements and standardized procedures.

• Review authorization requests that are initial, concurrent, urgent, and retrospective.

• Consult with providers regarding authorization requests.

• Collaborate with the Partners BHM physician on inquiries related to authorizations, enrollee health and safety, medication issues, response to services, and the necessity for Peer Review.

• Craft letters communicating the reasons for adverse decisions and options for appeal to both enrollees and providers.

⛳️ Requirements

• A Master’s degree in a Human Services field accompanied by clinical licensure and two years of post-Master’s behavioral health experience; or a Registered Nurse with two years of post-RN-degree behavioral health experience.

• Must be a resident of North Carolina.

• Hold a current unrestricted license with the appropriate professional licensure board in North Carolina.

• Possess a Registered Nurse license from the N.C. Board of Nursing, or an independent North Carolina license as an LCSW, LCMHC, LPA, or LMFT.

• An associate license does not fulfill the requirements.

• The LCAS cannot serve as a standalone license for working in UM.

• Maintain an active license by adhering to the continuing education and training requirements set by the licensure board.

• Extensive knowledge of mental illness, behavioral health principles, treatment options, and service provision.

• Familiarity with person-centered and recovery philosophies and interventions.

• Understanding of assessments and interventions related to mental health, developmental disabilities, and substance use disorders.

• Awareness of the 1915(b)(c) waiver.

• Knowledge of psychiatric medications and their side effects.

• Insight into evidence-based practices and cultural diversity.

• Proficiency in Microsoft Office applications, including Word, Excel, and Outlook.

• Capability to utilize complex telephone and computer systems and to document information electronically.

• Skill in making timely decisions based on relevant facts.

• Ability to independently manage multiple tasks, priorities, and an assigned caseload within stipulated deadlines.

🏝️ Benefits

• Annual incentive bonus plan.

• Medical, dental, and vision insurance featuring low deductible/low cost health plans.

• Generous accrual of vacation and sick time.

• 12 paid holidays.

• State Retirement (pension plan).

• 401(k) Plan with employer matching contributions.

• Company-covered life and disability insurance.

• Wellness Programs.

• Public Service Loan Forgiveness Qualifying Employer.