Clinical Care Reviewer II - RN - BH FOCUS - Compact Licensed

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