This role focuses on behavioral health utilization review for members receiving medically necessary care, with an emphasis on assessing requested services against clinical criteria and plan guidelines. The clinician reviews behavioral health cases, helps determine appropriate levels of care, and supports safe, timely access to treatment.
Key Responsibilities
- Conduct behavioral health utilization reviews for requested services and levels of care
- Review clinical information against medical necessity criteria and plan guidelines
- Coordinate with providers and internal teams to support timely authorization decisions
- Provide clinical input on treatment appropriateness, continued stay, and discharge planning
- Document review findings, decisions, and rationale in utilization management systems
- Participate in collaborative case discussions for complex behavioral health cases
Required
- Active RN licensure
- Experience in behavioral health or utilization review
- Knowledge of medical necessity criteria and utilization management processes
Preferred
- Prior managed care or health plan experience
- Experience with behavioral health authorizations or case review