Utilization Review Clinician - Behavioral Health

apartment Centene location_onPA

Utilization Review Clinician - Behavioral Health

$26.50 - $47.59 / HOUR

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. THIS POSITION IS REMOTE/WORK FROM HOME SUPPORTING PENNSYLVANIA HEALTH & WELLNESS BEHAVIORAL HEALTH UTILIZATION MANAGEMENT. APPLICANTS MUST EITHER HOLD AN ACTIVE PA LICENSURE; RN'S MUST HAVE A COMPACT LICENSURE AND BEHAVIORAL HEALTH EXPERIENCE. NEED TO BE ABLE TO ACHIEVE LICENSURE IN OTHER STATES AS REQUESTED BY THE COMPANY, COST WILL BE REIMBURSED. WORK SCHEDULE WILL BE MONDAY - FRIDAY 8AM - 5PM EASTERN TIME ZONE DURING TRAINING, AND AFTER TRAINING SCHEDULE CAN BE BETWEEN 8AM - 6PM. THERE WILL BE ROTATIONAL HOLIDAYS AND WEEKENDS FOR UP TO 4 HOURS TO ENSURE WE ARE MEETING REQUIRED TURN AROUND TIME FRAMES. 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. 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: $26.50 - $47.59 per hour 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

apartment Centene location_onIN

Utilization Review Clinician - Behavioral Health

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. 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. 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 For Fidelis Care only: LMSW, LCSW, LMHC, LPC, LMFT, LMHP or RN required 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

apartment PeaceHealth location_onBellingham, WA

RN Admissions/Utilization Behavioral Health - Care Management, 1.0 FTE, Day

$44.34 - $80.37 / HOUR

Description Job Description PeaceHealth is seeking a RN Admissions/Utilization Behavioral Health - Care Management for a Full Time, 1.00 FTE, Day position. The salary range for this job opening at PeaceHealth is $44.34 – $80.37. The hiring rate is dependent upon several factors, including but not limited to education, training, work experience, terms of any applicable collective bargaining agreement, seniority, etc. This position is represented by a collective bargaining agreement. There may be more than one opening on this posting. Hiring bonus and relocation assistance may be available. Job Summary Responsible for promoting effective utilization and monitoring of healthcare resources. This position will assume an informal leadership role with the multidisciplinary team to achieve optimal clinical, financial, and satisfaction outcomes. Essential Functions Acts as intermediary between the hospital and third party payors to ensure patients receive appropriate medically necessary inpatient psychiatric and medical services, so that the organization receives appropriate and optimal reimbursement. Understand and adhere to payer standards. Obtain voluntary admission authorization. Monitor accepted admissions from off hours and follow-up on payer authorization. Complete UR Admission review and Concurrent review processes. Ensure best use of limited inpatient resources by confirming accepted patients meet medical necessity criteria and will benefit from hospitalization. Ensure that all disciplines document to payer standards and demonstrate the need for continued hospitalization. Manage concurrent denials and some post discharge denials, submitting reconsideration clinical documentation. Assist provider in coordinating Peer to Peer with payer, as appropriate. Collaborate with PFS, UR Leaders, Payer contracting to ensure efficient work process in obtaining authorizations. Guide discussion with treatment team to improve quality, decrease cost and improve patient satisfaction. Document avoidable days. Verify patients on Single Bed Certifications and oversee UR process related to SBC encounter. ITA- monitor for change of status and notify payer. Provide admission support to Behavioral Health unit/ED/SECU as needed. Assist MSW with initial assessments, as appropriate. Ensure delivery of appropriate Medicare Notices. Assist MSW CM with medical transitions of care discharge planning such as medication pre-authorization, referrals to home health, procurement of DMW, SNF referrals, appt scheduling etc. Performs other duties as assigned. Qualifications Education Required: Degree from an Accredited School of Nursing Preferred: Bachelor of Science in Nursing Experience Strongly Preferred: Prior admission coordination or care management experience. Strongly Preferred: Working knowledge of psychiatric diagnostics. Preferred: Third party reimbursement knowledge. Preferred: Utilization Review experience. Credentials Required: Registered Nurse in state of practice Preferred: Psychiatric/Mental Health Clinical Nurse Specialist Skills Strong psychiatric nursing background. (Required) Must possess strong medical and psychiatric assessment, problem solving and prioritization skills and working knowledge of DSM 5 Revised. (Required) Excellent interpersonal skills required; must be professional in working closely with all customers such as referral sources, physicians, staff, patients and families. (Required) Good organizational skills and demonstrated ability to multi-task in a fast-paced environment. (Required) Ability to take direction from multiple sources and manage competing demands effectively. (Required) Requires excellent communication skills with the ability to communicate with people who have disabling conditions, or who have cultural differences, as well as clinicians less proficient with the needs of people with behavior issues. (Required) Proficient use of computers including MS Office applications and other applicable software applications. (Required) Working Conditions Lifting Consistently operates computer and other office equipment. Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. Sedentary work. Environmental Conditions Predominantly operates in an office environment. Some time spent on site in medical/hospital setting. Mental/Visual Ability to communicate and exchange accurate information. The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading. PeaceHealth is committed to the overall wellbeing of our caregivers: physical, emotional, financial, social, and spiritual. We offer caregivers a competitive and comprehensive total rewards package. Some of the many benefits included in this package are full medical/dental/vision coverage; 403b retirement plan employer base and matching contributions; paid time off; employer-paid life and disability insurance with additional buyup coverage options; tuition and continuing education reimbursement; wellness benefits, and expanded EAP and mental health program. See how PeaceHealth is committed to For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state, or federal laws.

Utilization Review Coordinator/Outpatient Nurse (RN) - Behavioral Health Setting

apartment UHS location_onLittleton, CO

Responsibilities Highlands Behavioral Health System is an 86 bed, acute care psychiatric hospital located in Littleton, CO. Highlands features individual units for adolescents, adults, and seniors, and offers inpatient acute care, partial hospitalization, and intensive outpatient programs. Website: https://highlandsbhs.com The Utilization Review Coordinator possesses knowledge of psychiatric clinical diagnosis and the ability to articulate those indicators professionally. The UM Coordinator manages medical necessity by evaluating the patient medical records to determine severity of patient’s illness and determining the appropriateness of level of care. Serves as liaison for patients and hospital with insurance companies. Negotiates and advocates for patient length of stay and level of care. Oversees utilization review activities with other departments to ensure reimbursement for services provided by the hospital. The UM Coordinator leads physician daily treatment team meetings, manages authorizations and reviews for outpatient programming and at time of admission is responsible for obtaining the precertification. The UM coordinator must be able to work with the business office and admissions departments to complete preliminary verification of benefits. The UM Coordinator has a working knowledge of all levels of care offered and appropriately manages patient benefits. This role will also act as the Outpatient RN and will assist with clinical screening of admissions, collaborating on treatment plans, interfacing with the treatment team, external case managers, and managed care organizations, and assisting the provider with provider visits and medication management as needed. Benefit Highlights: Tuition and Educational Reimbursement Program. Student Loan Repayment Program. Challenging and rewarding work environment Career development opportunities within UHS and its Subsidiaries Competitive Compensation & Generous Paid Time Off Excellent Medical, Dental, Vision and Prescription Drug Plans Discounts on pet insurance, automotive insurance & homeowners insurance 401(K) with company match and discounted stock plan Career development opportunities within UHS and its Subsidiaries SoFi Student Loan Refinancing Program More information is available on our Benefits Guest Website: benefits.uhsguest.com Questions or concerns? Contact the Human Resources department at HIGHLANDSBHSHumanResourceContact@uhsinc.com. Screening of applications begins immediately and continues until the position is filled. Qualifications Requirements: Current license to practice nursing in Colorado (or eligible to receive or renew). Graduate of an accredited School of Nursing or baccalaureate program. Clinical experience in psychiatric setting preferred. About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance, growing since its inception into a Fortune 500 corporation. Headquartered in King of Prussia, PA, UHS has 99,000 employees. Through its subsidiaries, UHS operates 28 acute care hospitals, 331 behavioral health facilities, 60 outpatient and other facilities in 39 U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. Avoid and Report Recruitment Scams We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters