Utilization Review Clinician - Behavioral Health (PIC)

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.

KEY DETAILS: This fully remote role with “Partnerships In Care” supports utilization management and quality improvement efforts by identifying outlier provider performance, conducting comprehensive clinical record reviews, and delivering individualized coaching to providers. The position also synthesizes findings into clear, actionable presentations for providers and health plan leadership. The Schedule is Monday through Friday 8-5 PM eastern, central, mountain, or pacific time zone. Preference will be given to applicants with (1) fully independent behavioral health social work, counseling, or therapy licenses (e.g. LCSW, LMHC, LCPC, LMFT), (2) experience in various mental health settings especially outpatient and residential treatment services, (3) utilization management / review, as well as (4) experience presenting to leadership/providers and advising providers on performance.

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.

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: $27.02 - $48.55 per hour

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.