Utilization Review Clinician - Behavioral Health

apartment Centene location_onFL

Utilization Review Clinician - Behavioral Health

$27.02 - $48.55 / 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. 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 Pay Range: $27.02 - $48.55 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_onNV

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. Hours: Monday-Friday; 8am-5pm or 9am-6pm PST. 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 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.

apartment PeaceHealth location_onEugene, OR

RN Admissions Coordinator/Utilization Review - Psychiatric Unit

$47 - $71 / HOUR

Description Job Description PeaceHealth is seeking a RN Admissions Coordinator/Utilization Review - Psychiatric Unit for a Per Diem/Relief, 0.00 FTE, Variable position. The salary range for this job opening at PeaceHealth is $47.34 – $71.00. 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. Responsible for identifying potential behavioral health inpatient unit candidates, pre-screening referrals, and preparing patients for admission to Behavioral Health Inpatient Unit, including patient consultation. Essential Functions Coordinates admissions; communicates and prioritizes, and provides for patient privacy; exercises discretion and assures confidentiality at all times. Assesses patient referrals to determine that patient meets all admission criteria. Collaborates with physicians, referral sources, and other staff to monitor issues and status; establishes timing of admissions. Coordinates the admission process with patients, families, referring facilities, physicians, emergency departments’ crisis workers, public safety officers, outside agencies and Behavioral Health Inpatient Unit staff. Provides documentation of medical necessity and obtains authorization for treatment regarding acute inpatient psychiatric benefits. Identifies patients in need of financial assistance and refers to the appropriate programs. Performs data collection and statistical compilation and analysis of data bases relative to quality assurance and effectiveness of programs. Provides professional psychiatric nursing presence and oversight based on unit needs. Performs other duties as assigned. What you bring: Accredited School of Nursing Required Bachelor's Degree Preferred: Mental Health Bachelor's Degree Preferred: Health Services Bachelor's Degree Preferred: Nursing or Bachelor's Degree: Health Sciences Required: Must have strong psychiatric nursing background and previous admission coordination experience Required: Registered Nurse in state of practice Preferred: Psychiatric Mental Health Nursing Department / Location Specific Notes Oregon: Assumes job functions of a Transfer Coordinator as needed. CareConnect access. PeaceHealth is committed to the overall wellbeing of our caregivers. The benefits included in positions less than 0.5 FTE are 403b retirement plan for caregiver contributions; wellness benefits, discount program, 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.

Manager/Supervisor