Utilization Behavioral Health Professional Jobs

2 years Mental Health experience preferred.

The Therapist responsibilities include, but are not limited to, the following:

Provides documentation daily in the chart of each patient.

Facilitates discharge planning to assist patients in placement and treatment following discharge from current level of care.

Participates in the writing of treatment plans and attends treatment team meetings.

Facilitate the completion of Emergency Detention paperwork as well as ensure its distribution and receipt by legally designated individuals.

Invites you to apply for:

BEHAVIORAL HEALTH UTILIZATION REVIEW SPECIALIST

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Two or more years of behavioral health experience.

Strong problem solving skills and decision making skills.

This position requires residency in the state of North Carolina.

Current active professional licensure required in North Carolina: LCMHC, LCSW, RN

Proficiency in Microsoft Office, including Word, Excel and Outlook is required.

Ability to communicate in a positive/professional manner both orally and written.

Starts at $30-31+ per hour based on experience, education, and certifications.

Possess one of the following certifications: (RN, DC, PT, DPT, LVN, OT, LAc).

1 year of clinical experience

Knowledgeable with computer programs (MS Word, MS Excel, Email) and toggling between multiple screens.

Medical, Dental & Vision Insurance

Paid Time Off & Paid Holidays

At least years of experience in negotiating managed care contracts with physician, hospital and/or other provider contracts

Experience with behavioral health contracting

Excellent written and verbal communication skills

Ability to manage multiple priorities in a fast-paced environment

Experience working with Medicaid contracts

This is a remote position; however, candidates must reside in the state of Indiana.

Position can be done Remote (work from home)

Education: Registered Nurse or Masters in Social Work, Counseling or Psychology.

Broad Knowledge of mental illness/substance use diagnosis and treatment protocols required.

Computer skills and an advanced understanding of the Electronic Health Records used by the department required.

The abilities to work independently to triage incoming requests and clearly communicate work assignments and priorities to the department are essential.

Overview: Behavioral Health (Utilization/Case Manager)

Computer skills in word processing, database management, and spreadsheet desirable.

Knowledge in areas of: Medicare and Medicaid UM regulations, McKesson InterQual, and Denial Management.

Two (2) years of experience in Acute Clinical Care or Medical Management setting, adult and children.

Identifies members that are high risk or have conditions that may need case or disease management.

Enters and maintains pertinent clinical information in health management system.

Participates in utilization management committees and works on special projects related to utilization management as needed.

Provides educational services to the Utilization Management staff

Requires knowledge of managed care contracting, Medical Necessity, CMHRS services, DMAS protocols, clinical protocols and clinical review requirements

Minimum 1 year experience in Managed Care Setting (MCO)

First line supervisor in the Utilization Management Department

Provides a leadership role in ongoing utilization review competency assessment, needs identification and educational offerings

Requires knowledge of contractual, regulatory and compliance requirements for government payers, self funded and commercial payers

Demonstrated knowledge of payers, payer systems, cost effective utilization management and InterQual criteria.

One year Utilization Review or Case Management experience.

Knowledge / Skills / Abilities

Upload most recent updated resume with work history and experience, please include Month and Year in formatting.

Alerts and discusses with physician/provider and case manager/discharge planner when patient no longer meets medical necessity criteria for the inpatient stay.

Demonstrated team leadership, relationship building, critical analysis, and written and verbal communication skills.

Excellent data entry skills and ability to navigate electronic systems applicable to job functions

Ensure all pre-certifications are completed for inpatient and outpatient services

Work with facilities to ensure documentation requirements are met

Interface with managed care organizations, external reviews, and other payers

2 or more years experience billing UR healthcare industry – in the mental health/addiction field.

Working knowledge of clinical case formulation for substance abuse/mental health treatment.

Appropriate and complete documentation of clinical review and denial management in the case management documentation system and in the billing system.

Position Qualifications Required / Experience Required:

Manages the concurrent denial process by referring to appropriate resource for concurrent and retrospective appeal activity process.

Understands and applies applicable federal and state requirement.

Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.

Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues.

5-8 years post-master’s direct clinical experience, including utilization management in behavioral health or managed care

Provide monthly Care Management report on team(s) performance, metrics, and goal achievement to the Director of Behavioral Health.

Demonstrated understanding and proficiency in the principles, concepts and techniques of managed care and utilization management.

Able to manage ambiguity and change, and lead a team’s effective management of shifting priorities, competing demands, and rapidly changing conditions.

5-8 years of supervisory experience preferred

Experience with Medicare and Medicaid

Provide direct oversight to a utilization management team, for employees at multiple locations across the country (remote)

3+ years of people management experience (managing direct reports, coaching, training, performance reviews, running team meetings, etc.)

Proven excellent communication, collaboration, team building and relationship management skills

Provides leadership to and is accountable for the performance of managers and/or senior level professional staff

5+ years of experience managing a clinical/operational unit in a broad range of settings

Experience interfacing with providers and solutioning gaps

Coordinate utilization management reviews for all assigned inpatient, partial hospitalization and intensive outpatient program patients.

Coordinates closely with Director of Utilization Management, Nursing and Clinical Services.

Follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with external review agencies.

Obtains authorizations for services, coordinates peer-to-peer reviews for assigned caseload.

Understands medical necessity criteria and facilitates accurate and timely documentation to support advocacy of services.

Master’s Degree in Social Work, Marriage and Family Therapy or Counseling from an accredited school or BSN, RN

Provide self-management support and development of self-management plans and/or relapse prevention plans so that clients can attain personal health goals.

Promote self-direction and skill development in the area of independent administering of medication and medication adherence.

Work with managed care organizations to verify continued client eligibility and funding.

Ability to practice good verbal and written communication skills with ability to complete case notes timely and other required documentation.

One year experience working with population served.

Development – We believe equipping you with support and development opportunities is an essential part of delivering a remarkable employment experience.

Above average PC skills, ability to work, ability to multi task using multiple systems during call processing

You can reach me at

Pleasefind below the detailed job description:

Term: 9+ months (Contract with possible extension)

Shift: Tuesday 6am-4pm, Thursday, Friday, and Saturday 10am-8pm

Describe the performance expectations/metrics for this individual and their team:

Utilization management experience, preferably in an outpatient setting.

Coordinates with Care Coordination and Case Management.

Three (3) or more years of post-degree clinical experience in direct patient care.

Three (3) or more years of Behavioral Health experience.

Experience working in electronic medical records.

Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

Possesses skill set to provide clerical support to the Case Management Department.

Excellent time management skills with a proven ability to meet deadlines.

Demonstrates knowledge and skill set to process BHU Medical TARS

Regularly attends required in-services and continuously takes an active interest in furthering one's knowledge.

Has the willingness and ability to perform all other duties and responsibilities as assigned

Five years + experience in acute care hospital Utilization Review and RN Required

Demonstrates clinical knowledge, including an understanding of the case management process.

Detail oriented with strong organizational skills including the ability to manage time wisely to meet established deadlines.

Strong computer skills including working knowledge of Word, Windows based applications, typing and internet access.

Excellent oral and written communication skills.

Experience with situations requiring strict adherence to confidentiality.

Ability to professionally communicate with customers, and all interdisciplinary team members.

Identify high cost utilization and refer to Large Case Reinsurance RN and Care Management team as appropriate.

Coordinate necessary resources to achieve member outcome goals and objectives.

Accurately document case notes and letters of explanation which may become part of legal records.

Perform concurrent review of members admitted to inpatient facilities, residential treatment centers, and partial hospitalization programs.

Maintain contact with the inpatient facility utilization review personnel to assure appropriateness of continued stay and level of care.

Review referral and preauthorization requests for appropriateness of care within established evidence-based criteria sets.