This role focuses on reviewing behavioral health and medical services to support appropriate care decisions for members. The clinician evaluates requests against clinical criteria, coordinates with providers as needed, and helps guide members toward the right level of care.
Key Responsibilities
- Conduct clinical review of medical and behavioral health service requests.
- Apply utilization management criteria to determine medical necessity and level of care.
- Coordinate with providers and internal care teams to clarify clinical information.
- Document review findings and authorization decisions accurately in workflow systems.
- Support timely, appropriate access to services through review and escalation processes.
- Participate in care coordination and utilization review activities as assigned.
Required
- Active RN license or behavioral health clinical license.
- Clinical experience in utilization review, case management, or a related care review setting.
- Knowledge of medical necessity review and authorization processes.