Behavioral Health Utilization Reviewer

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

📋 Description

• Perform clinical assessments of requests for behavioral health services, claims, and appeals.

• Evaluate pre-authorization submissions, ongoing reviews, and retrospective claims in behavioral health.

• Utilize InterQual and medical policy standards to establish medical necessity.

• Escalate cases that do not satisfy criteria to the Psychiatric Medical Director for further evaluation.

• Assist the appeals department in reviewing provider and member appeals in accordance with regulatory deadlines.

• Engage with behavioral health care providers regarding level-of-care and service determinations.

• Record clinical decisions and the rationale behind them in the utilization management system.

• Convey decisions to providers and members through both phone and written communication.

• Examine behavioral health member data to enhance quality and proper service usage.

• Collaborate with Case Management, Quality, Provider Relations, and other internal teams.

• Ensure compliance with CMS, NCQA, URAC, as well as other state, federal, and accreditation mandates.

• Take part in audits, training sessions, and quality improvement efforts.

• Carry out additional job-related tasks as required within the scope of responsibilities.

⛳️ Requirements

• Preference for residency in or relocation to Louisiana.

• Must have authorization to work for Louisiana Blue in the U.S. without employer-sponsored immigration assistance.

• Bachelor's degree in nursing, healthcare, or a related discipline OR a master’s degree in social work, counseling, or behavioral health.

• A Louisiana RN license may substitute for the bachelor's degree.

• A Louisiana LPN license coupled with 2 years of relevant experience can also replace the bachelor's degree.

• Minimum of 3 years of clinical or patient care experience in behavioral health is required.

• Must possess one of the following licenses: LPC, PLPC, LCSW, LMFT, LMSW, LPN, or RN.

• Strong clinical evaluation and critical-thinking abilities are essential.

• Exceptional communication and teamwork skills are necessary.

• Solid understanding of behavioral health conditions and their treatments.

• Ability to work independently while adhering to policies.

• Preferred: experience in managed care or health insurance settings.

• Preferred: familiarity with CPT coding and billing practices.

• Preferred: experience working with Medicare and commercial populations.

• Preferred: proficiency in electronic health records and case management systems.

• Ability to meet the physical demands and essential functions of the position.

• Must complete a background check and pre-employment drug screening after receiving an offer and before hiring.

• Individuals with felony convictions involving dishonesty or breach of trust must acquire written consent from their state insurance commissioner to work in the insurance industry.

🏝️ Benefits

• Access to resources aimed at promoting health and well-being.

• Opportunities for ongoing learning and skill enhancement.

• Career advancement prospects.

• Chances to contribute to local communities.

• Reasonable accommodations available for individuals with disabilities.

• A smoke- and tobacco-free workplace environment.

• Background checks and pre-employment drug screenings are required.