Clinical Care Reviewer II – Behavioral Health, Prefer MA Licensed

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

📋 Description

• Conduct reviews of medical necessity to assess the appropriateness of behavioral health care service authorizations.

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

• Coordinate member care effectively.

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

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

• Collaborate with the medical director when additional clinical expertise is required.

• Stay informed about state and federal regulations, state contracts, provider agreements, benefits, and accreditation standards.

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

• Identify and refer suitable members for Care Management.

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

• Participate in medical advisement and State Hearing meetings as needed.

• Assist the Team Leader with special projects or research upon request.

• Perform additional job-related tasks as requested.

⛳️ 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.

• Current, unrestricted licensure as a Registered Nurse (RN), 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 mandatory or must be obtained within six (6) months of hire.

• Experience in Utilization Management/Utilization Review is preferred.

• Familiarity with Medicaid, Medicare, or Commercial experience is preferred.

• Strong data entry skills and the ability to successfully navigate clinical platforms are essential.

• Proficient in Microsoft Outlook, Word, and Excel.

• Excellent oral and written communication abilities.

• Capability to work both independently and collaboratively within a team.

• Strong attention to detail.

• Proper grammar usage and effective phone etiquette are required.

• Strong time management and prioritization abilities.

• Customer service-oriented mindset.

• Proficient decision-making and problem-solving skills.

• Exceptional organizational skills.

• Ability to adapt to change effectively.

🏝️ Benefits

• Bonus linked to both company and individual performance.

• Extensive and comprehensive total rewards package.

• Support for total employee well-being.