Clinical Care Reviewer II – Behavioral Health

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

📋 Description

• Conduct reviews of medical necessity for the authorization of behavioral health care services.

• Support discharge planning initiatives, which include outpatient and home health services.

• Facilitate care coordination for members.

• Execute prospective, concurrent, and retrospective evaluations of Behavioral Health services.

• Identify, document, communicate, and coordinate care with collaborative partners to ensure a smooth transition to the appropriate level of care.

• Collaborate with the medical director when further clinical insights are required.

• Stay informed about state and federal regulations, State Contracts, Provider Agreements, benefits, and accreditation standards.

• Recognize and refer quality issues to the Quality Improvement team.

• Identify and refer suitable members for Care Management.

• Provide support and guidance to non-clinical staff and assist LPN staff.

• Attend medical advisement and State Hearing meetings upon request.

• Assist the Team Leader with special projects or research as needed.

• Carry out additional job-related responsibilities as assigned.

⛳️ Requirements

• An Associate of Science (A.S) in Nursing, a Bachelor of Science (B.S) in Social Work, or a Master's degree in a mental health-related field is required.

• A minimum of three (3) years of clinical experience is required.

• Experience in Utilization Management/Utilization Review is preferred.

• Familiarity with Medicaid, Medicare, and Commercial insurance is preferred.

• Proficient data entry skills and the ability to effectively navigate clinical platforms.

• Working knowledge of Microsoft Outlook, Word, and Excel.

• Strong oral and written communication skills.

• Ability to work independently as well as collaboratively within a team.

• High attention to detail.

• Proficient use of grammar and professional phone etiquette.

• Excellent time management and prioritization abilities.

• Customer service-oriented mindset.

• Strong decision-making and problem-solving skills.

• Exceptional organizational skills.

• Resilient to change.

• Current, unrestricted Registered Nurse (RN) License, Licensed Social Worker (LSW), Licensed Clinical Social Worker (LCSW), Licensed Independent Clinical Social Worker (LICSW), Associate Clinical Social Worker (ACSW), Licensed Mental Health Counselor (LMHC), Licensed Professional Counselor (LPC), Licensed Marriage & Family Therapist (LMFT), or Licensed Mental Health Practitioner (LMHP) is required.

• MCG Certification is required or must be obtained within six (6) months of employment.

🏝️ Benefits

• Potential bonus linked to both company and individual performance.

• A substantial and comprehensive total rewards package.

• Remote work arrangement.