利用审查临床医生（行为健康）
Utilization Review Clinician - Behavioral Health
职位职责：进行临床审查，评估与心理健康和物质滥用相关的护理情况。监控并确定与心理健康和物质滥用相关的护理级别和服务是否符合医学要求。
关键信息：这是一个完全远程的职位，由“Partnerships In Care”提供支持，通过识别异常的提供者表现、进行全面的临床记录审查，并为提供者提供个性化指导，来支持利用管理质量和改进工作。该职位还将分析结果整理成清晰、可操作的报告，供提供者和保险公司管理层参考。工作时间是周一至周五，东部、中部、山区或太平洋时区的上午8点至下午5点。优先考虑具备以下条件的申请人：（1）拥有完全独立的心理健康社会工作、咨询或治疗执照（例如LCSW、LMHC、LCPC、LMFT），（2）在各种心理健康环境中工作的经验，特别是门诊和住院治疗服务，（3）利用管理/审查经验，以及（4）向管理层/提供者进行汇报并就表现提供建议的经验。
- 在服务前、中、后评估成员的心理健康和物质滥用治疗，以确保护理级别和服务符合医学要求
- 进行与心理健康和物质滥用相关的预先授权审查，根据监管指南和标准确定医学适当性
- 对行为健康（BH）住院患者进行同期审查，以确定成员的整体健康状况、治疗需求和出院计划
- 分析BH成员数据，以提高服务质量和适当的使用率
- 为提供者、成员及其家庭提供有关BH使用流程的教育
- 根据需要与BH医疗提供者互动，讨论护理级别和/或服务
- 与医疗主任和管理层合作，提高护理质量和效率
- 在人员配置和整合会议中制定并展示案例
- 执行其他指派的任务。
- 遵守所有政策和标准。
教育/经验：需要毕业于认证的护理学校或获得学士学位，并有2-4年相关工作经验。
需具备独立执业的执照，或已获得相关州规定的执照。
行为健康临床人员需具备硕士学位。
临床知识和能力，能够进行...
查看英文原文
Position Purpose: Performs a clinical review and assesses care related to mental health and substance abuse. Monitors and determines if level of care and services related to mental health and substance abuse are medically appropriate.
KEY DETAILS: This fully remote role with “Partnerships In Care” supports utilization management and quality improvement efforts by identifying outlier provider performance, conducting comprehensive clinical record reviews, and delivering individualized coaching to providers. The position also synthesizes findings into clear, actionable presentations for providers and health plan leadership. The Schedule is Monday through Friday 8-5 PM eastern, central, mountain, or pacific time zone. Preference will be given to applicants with (1) fully independent behavioral health social work, counseling, or therapy licenses (e.g. LCSW, LMHC, LCPC, LMFT), (2) experience in various mental health settings especially outpatient and residential treatment services, (3) utilization management / review, as well as (4) experience presenting to leadership/providers and advising providers on performance.
- Evaluates member’s treatment for mental health and substance abuse before, during, and after services to ensure level of care and services are medically appropriate
- Performs prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria
- Performs concurrent review of behavioral health (BH) inpatient to determine overall health of member, treatment needs, and discharge planning
- Analyzes BH member data to improve quality and appropriate utilization of services
- Provides education to providers members and their families regrading BH utilization process
- Interacts with BH healthcare providers as appropriate to discuss level of care and/or services
- Engages with medical directors and leadership to improve the quality and efficiency of care
- Formulates and presents cases in staffing and integrated rounds
- Performs other duties as assigned.
- Complies with all policies and standards.
Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 2 – 4 years of related experience.
License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state required.
Master’s degree for behavioral health clinicians required.
Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse preferred.
Knowledge of mental health and substance abuse utilization review process preferred.
Experience working with providers and healthcare teams to review care services related to mental health and substance abuse preferred.
License/Certification:
- LCSW- License Clinical Social Worker required or
- LMHC-Licensed Mental Health Counselor required or
- LPC-Licensed Professional Counselor required or
- Licensed Marital and Family Therapist (LMFT) required or
- Licensed Mental Health Professional (LMHP) required or
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required
Pay Range: $27.02 - $48.55 per hour
At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Originally posted on Himalayas