This role reviews behavioral health cases remotely, applying clinical judgment to assess medical necessity, care plans, and utilization of services for members in Florida. The work focuses on behavioral health review decisions, coordination with internal teams, and documentation that supports timely, appropriate care.
Key Responsibilities
- Review behavioral health authorizations, treatment requests, and related clinical records for medical necessity and appropriateness of care.
- Use clinical guidelines and plan criteria to support coverage determinations and care review decisions.
- Coordinate with providers, care teams, and internal staff to gather additional information and clarify cases as needed.
- Document review findings, determinations, and rationales accurately in the utilization management workflow.
- Participate in processes that support timely case turnaround, quality, and consistent review standards.
Required
- Active behavioral health clinical license in Florida.
- Experience in behavioral health clinical review, utilization management, or a related care management setting.
- Ability to work remotely in Florida.
Preferred
- Prior experience with utilization review or medical necessity determination.
- Familiarity with managed care, health plan operations, or payer-based clinical workflows.
- Experience working with behavioral health populations across outpatient or higher levels of care.