Position Summary
Fully remote role. Monday - Friday 8:30 - 5:00 pm EST
Utilizes clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program for Medicare Integrated/dually eligible member populations. Applies critical thinking and clinical judgment grounded in evidence-based care and clinical practice guidelines for behavioral health and/or medical conditions, based on program focus. Supports care coordination and benefit management across complex member needs, with attention to quality, service, and appropriate resource use.
Key Responsibilities
- Apply clinical expertise to review and evaluate treatment plans across various levels of care, ensuring alignment with evidence-based standards, clinical guidelines, and applicable benefit coverage criteria.
- Coordinate, monitor, and assess healthcare service options to help ensure Medicare Integrated/dually eligible members receive appropriate, cost-effective care.
- Collect and assess clinical information to determine coverage recommendations, including discharge planning, transitions of care, and coordination of services for members with complex medical, behavioral health, and psychosocial needs.
- Collaborate with providers, care teams, and interdisciplinary partners to facilitate optimal treatment outcomes and support continuity of care.
- Identify high-risk members and connect them with appropriate internal programs, services, community resources, or additional supports.
- Recognize opportunities to enhance the quality and effectiveness of healthcare services while optimizing benefit use for a complex, high-need member population.
- Serve as a clinical resource to internal teams and external partners regarding utilization management processes, member needs, and coordination requirements.
- Perform responsibilities while working primarily at a computer, including extended periods of phone communication.
Required Qualifications
- Must be able to work the posted schedule. The role requires rendering decisions within mandated turnaround times; therefore, schedule flexibility is limited.
- Active, current, and unrestricted Master's-level behavioral health clinical license in the state of residence (e.g., LMSW, LCSW, LISW, LPC, or comparable), or Registered Nurse licensure in the state of residence with psychiatric specialty, certification, or relevant experience.
- 1+ years of behavioral health utilization review/utilization management experience required.
- 3+ years of experience in an inpatient hospital setting working with behavioral health members. Experience must be recent, or supported by continuous, behavioral health-focused work since the inpatient setting experience.
Preferred Qualifications
- Experience working with Medicare, Medicaid, or dually eligible populations.
- Experience working with geriatric or chronically mentally ill populations.
- Experience supporting high-risk member populations.
- Strong computer proficiency, including navigating multiple systems and accurate keyboarding.
Education
- Master's degree in a behavioral health field, or Registered Nurse degree (BSN preferred)
Anticipated Weekly Hours: 40
Time Type: Full time
Pay Range
The typical pay range for this role is
$26.01 - $68.55