Utilization Management, Clinical Consultant - Ohio

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Position Summary

OhioRISE manages the behavioral health benefit for eligible children and young adults receiving Medicaid services in Ohio. The Behavioral Health UM Clinician position is designed to clinically review of behavioral health prior authorized services for assigned members. This particular role will be to support the prior authorization and concurrent reviews for medical necessity for youth in a Psychiatric Residential Treatment Facility (PRTF).

The Behavioral Health UM Clinician position is a full-time benefits eligible position. Work schedule consideration may be Monday-Friday during the hours of 8:00am-5:00pm. This is a 100% remote position.

On-call and holiday coverage may be required.

Key Responsibilities

Utilize clinical expertise to coordinate, document, and communicate all aspects of the utilization management and benefit determination process.

Conduct clinical reviews using evidence-based criteria, clinical practice guidelines, and sound clinical judgment to assess the medical necessity, appropriateness, and quality of services across the continuum of care.

Gather, analyze, and interpret clinical information to render coverage determinations and recommendations, including effective discharge and transition planning.

Coordinate and monitor treatment options and healthcare services to ensure members receive appropriate, high-quality, and cost-effective care.

Recognize and communicate quality of care concerns, patient safety issues, treatment gaps, and other clinical risks, including presenting and discussing cases with health plan physicians and interdisciplinary teams.

Participate in case staffing, interdisciplinary rounds, and clinical discussions, confidently presenting clinical information, treatment recommendations, and utilization management considerations.

Support a collaborative team environment by assisting colleagues in managing and balancing a collective caseload, ensuring timely reviews and consistent service delivery.

Identify opportunities to improve quality, effectiveness, and utilization of healthcare services through clinical insight and ongoing evaluation of care delivery practices.

Serve as a clinical resource and subject matter expert for internal and external stakeholders regarding utilization management processes, clinical guidelines, and benefit administration.

Required Qualifications

Active, current, and unrestricted Independently Licensed Master's‑level Behavioral Health Clinician licensed in Ohio, (e.g., LISW, LPCC, or comparable) or Registered Nurse licensure with psychiatric specialty, certification, or experience.

1+ years of Utilization Review/Utilization Management experience required.

3+ years of Behavioral Health clinical experience in a hospital setting.

Recent experience in an inpatient hospital behavioral health setting, or continuous, recent behavioral‑health‑focused work since that experience.

Ability to meet mandated decision turnaround times with limited schedule flexibility.

Minimum of two years' experience in children's behavioral health, child welfare, developmental disabilities, juvenile justice, or a related public sector human services or behavioral health care field,providing community-based services to children and youth, and their family/caregivers.