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Behavioral Health Utilization Management Reviewer
The Behavioral Health Utilization Management Reviewer is responsible for performing utilization review activities for behavioral health services to ensure medical necessity, appropriate level of care, and compliance with clinical guidelines and benefit policies. This role involves reviewing clinical information, applying evidence-based criteria, and collaborating with providers, members, and interdisciplinary care teams to promote high-quality, cost-effective care.
This position requires licensure as a Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW)
Key Responsibilities:
- Conduct timely utilization reviews for behavioral health inpatient and outpatient services using established clinical criteria (e.g., MCG, InterQual, ASAM).
- Evaluate treatment plans and clinical documentation to determine medical necessity and appropriateness of care.
- Communicate review outcomes to providers, members, and internal stakeholders, including approvals, denials, and peer review referrals.
- Collaborate with care management, provider relations, and quality departments to coordinate continuity of care and optimize outcomes.
- Document all review activities in accordance with regulatory and organizational standards.
- Participate in interdepartmental meetings and case discussions.
- Maintain up-to-date knowledge of behavioral health treatment modalities, coding, benefits, and regulatory requirements (e.g., CMS, NCQA, URAC).
- Serve as a resource for behavioral health clinical expertise within the utilization management team.
Required:
- Active, unrestricted license as an RN or LCSW.
- 3+ years of clinical experience in behavioral health (e.g., inpatient psych, outpatient therapy, case management, substance use treatment)
- Background with Applied Behavior Analysis (ABA)
- Experience in utilization management, case review, or managed care environment
Preferred:
- Experience with managed care organizations (MCOs), insurance plans, or behavioral health utilization review
- Familiarity with UM criteria sets (e.g., InterQual, MCG, ASAM)
- Knowledge of Medicaid, Medicare, or commercial insurance regulations
Skills and Competencies:
- Strong clinical judgment and critical thinking
- Excellent communication skills, both verbal and written
- Ability to interpret and apply clinical guidelines
- Comfortable with electronic medical records (EMRs), UM software, and case management platforms
- Organized, detail-oriented, and able to manage multiple priorities
Working Conditions:
- Full-time; may require occasional evenings or weekends based on workload
- Remote or office-based depending on organizational policy
- May involve phone-based or electronic review work
Job Types: Full-time, Contract
Pay: From $45.00 per hour
Experience:
- clinical experience in behavioral health: 3 years (Required)
- Applied Behavior Analysis (ABA): 3 years (Required)
- Utilization Management: 3 years (Required)
License/Certification:
- RN License (Required)
Work Location: Remote
