This role focuses on behavioral health utilization management, reviewing psychiatric and mental health services for medical necessity and appropriate level of care. The clinician evaluates requests, applies evidence-based criteria, and helps coordinate decisions that support timely access to covered behavioral health treatment. Work is likely desk-based and collaborative, with interaction across clinical and operational teams.
Key Responsibilities
- Review behavioral health and psychiatric service requests for medical necessity and level-of-care appropriateness.
- Apply utilization management criteria, clinical guidelines, and plan policies to case reviews.
- Conduct chart reviews and support authorization decisions for mental health services.
- Coordinate with other clinicians and internal teams to clarify clinical information and resolve cases.
- Document review findings, determinations, and rationale in the utilization management workflow.
- Support timely processing of requests to help members access appropriate behavioral health care.
Required
- Active Nurse Practitioner license.
- Psychiatric-Mental Health Nurse Practitioner (PMHNP) training or certification.
- Experience or background in behavioral health or mental health care.