Job Summary
Performs behavioral health utilization reviews, applying evidence-based criteria, and collaborating with physicians to ensure clinically appropriate, cost-effective, and regulatory-compliant care determinations. Assists in evaluating medical necessity, ensuring timeliness, and supporting the consistency of clinical decision-making across markets. Participates in a team-based, physician-led model that aligns with national clinical oversight standards and enterprise behavioral health initiatives. Contributes to overarching strategy to provide quality and cost-effective member care.
Essential Job Duties
- Performs behavioral health utilization management reviews for inpatient, outpatient, and intermediate level services using nationally recognized criteria (e.g., MCG, InterQual, ASAM).
- Reviews medical documentation to determine the medical necessity, level of care, and continued stay appropriateness for behavioral health services.
- Collaborates with behavioral health medical directors on complex or borderline cases - ensuring consistent application of criteria and alignment with regulatory standards.
- Identifies quality of care, safety, and compliance concerns and escalate to the medical director as appropriate.
- Maintains compliance with federal, state, and accreditation requirements (e.g., National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), Centers for Medicare and Medicaid Services (CMS)).
- Participates in utilization management quality audits, internal case reviews, and peer-to-peer education.
- Supports process improvement initiatives and contributes to the development of clinical review guidelines and training materials.
- Works under the medical direction and supervision of a licensed physician, consistent with state law and corporate policy.
- Obtains and maintains multi-state licensure to support national coverage needs.
- Participates in enterprise behavioral health workgroups, scoreable action items (SAIs), and other cross-functional initiatives as assigned.
- Provides input to leadership regarding utilization management workflow optimization and emerging utilization trends.
Required Qualifications
- At least 5 years of experience as a registered nurse or nurse practitioner in managed care, behavioral health or utilization management, or equivalent combination of relevant education and experience.
- Psychiatric-Mental Health Nurse Practitioner (PMHNP), and ability to obtain cross-state licensure as required. License must be active and unrestricted in state (WI) of practice.
- Current national certification (PMHNP-BC) from the American Nurses Credentialing Center (ANCC).
- Demonstrated experience in the application of medical necessity criteria and regulatory guidelines.
- Strong customer service/member-centric focus.
- Electronic Medical Record (EMR) proficiency.
- Responsive in all forms of communication, and ability to remain calm in high-pressure situations.
- Strong time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.
- Problem-solving skills.
- Ability to work within a variety of settings and adjust style as needed, including ability to work with diverse populations, various personalities and personal situations.
- Ability to work independently, with minimal supervision and demonstrate self-motivation.
- Ability to work cross-collaboratively within a highly matrixed organization.
- Excellent verbal and written communication skills.
- Microsoft Office suite/applicable software program(s) proficiency.
Preferred Qualifications
- Prior experience in a managed care organization or payer-based utilization management setting.
- Familiarity with Medicaid, Marketplace, and Medicare behavioral health regulations.
- Strong working knowledge of clinical criteria (e.g., ASAM, MCG, InterQual).
- Computer proficiency and experience with electronic medical record (EMR) or utilization management systems.
Pay Range: $79,607.9 - $172,483.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.