Utilization Review Clinician - Behavioral Health
Core
Performs clinical reviews and assessments of mental health and substance abuse care to determine medical appropriateness of level of care and services.
Role type
Utilization Review Clinician (Behavioral Health)
Builds
Clinical review reports, prior authorization decisions, concurrent review findings, and actionable presentations for providers and leadership.
Domain
Healthcare / Behavioral Health / Utilization Management
Required skills
Behavioral health clinical assessment, Prior authorization review, Concurrent review of inpatient care, Data analysis for utilization improvement, Provider education, Regulatory guideline compliance
Preferred skills
Independent behavioral health license (LCSW, LMHC, LCPC, LMFT, LMHP, RN), Outpatient and residential treatment experience, Utilization management process knowledge, Provider performance advising
Technologies
Electronic Health Records (EHR), Utilization Management Software
Responsibilities
Evaluate member treatment for mental health and substance abuse before, during, and after services; Perform prior authorization reviews; Perform concurrent review of BH inpatient; Analyze BH member data; Provide education to providers and families; Interact with healthcare providers to discuss level of care; Engage with medical directors to improve care quality; Formulate and present cases in staffing rounds.
Seniority
Mid-level (2–4 years experience)