Clinical Care Reviewer II - Behavioral Health

Job Summary:

Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services) and care coordination for members.

Essential Functions:

Complete prospective, concurrent and retrospective review of Behavioral Health services

Identify, document, communication and coordinate care engaging collaborative care partners to facilitation transition to an appropriate level of care

Engage with medical director when additional clinical expertise if needed

Maintain knowledge of state and federal regulations, including State Contracts and Provider Agreements, benefits, and accreditation standards

Identify and refer quality issues to Quality Improvement

Identify and refer appropriate members for Care Management

Provide guidance to non-clinical staff

Provide guidance and support to LPN staff

Attend medical advisement and State Hearing meetings, as requested

Assist Team Leader with special projects or research, as requested

Perform any other job related duties as requested.

Education and Experience:

Associates of Science (A.S) in Nursing required or

Bachelor of Science (B.S) in Social Work required or

Master's degree in a mental health related field (Psychology, Counseling Psychology, Marriage or Family Therapy) required

Three (3) years clinical experience required

Utilization Management/Utilization Review experience preferred

Medicaid/Medicare/Commercial experience preferred

Competencies, Knowledge and Skills:

Proficient data entry skills and ability to navigate clinical platforms successfully

Working knowledge of Microsoft Outlook, Word, and Excel

Effective oral and written communication skills

Ability to work independently and within a team environment

Attention to detail

Proper grammar usage and phone etiquette

Time management and prioritization skills

Customer service oriented

Decision making/problem solving skills

Strong organizational skills

Change resiliency

Licensure and Certification:

Current, unrestricted Registered Nurse (RN) Licensure, 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) required

MCG Certification is required or must be obtained within six (6) months of hire required

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time

Travel is not typically required

Compensation Range:

$62,700.00 - $100,400.00

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Hourly

Organization Level Competencies

Fostering a Collaborative Workplace Culture

Cultivate Partnerships

Develop Self and Others

Drive Execution

Influence Others

Pursue Personal Excellence

Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

Brand=CareSource

Originally posted on Himalayas