Clinician Jobs in Raleigh, NC

LOCATION : Remote – this is a home-based, virtual position. Incumbent must live in North Carolina or within 40 miles of the NC border.

GENERAL STATEMENT OF JOB

The Mental Health / Substance Use (MHSU) Utilization Management (UM) Clinician provides multiple utilization review tasks, including review of Service Authorization Requests (SARs), Person-Centered Plans (PCPs) / Treatment Plans and clinically relevant documentation for authorization of clinically appropriate services. The MHSU Utilization Management Clinician works with service providers to facilitate appropriate service planning and service provision. The MHSU Utilization Management Clinician will provide other clinical reviews, and case consultations to facilitate the provisions of clinically appropriate services to members with mental health and substance use disorders.

ESSENTIAL JOB FUNCTIONS

Review Service Authorization Requests (SARs) :

• Review PCPs / Treatment Plans submitted by providers with authorization requests
• Where plans do not meet established standards for medical necessity, provide feedback and request additional information from providers, including consultation and education as appropriate
• Authorize requested services meeting authorization requirements and medical necessity
• Send Educational Notifications for requests not meeting sufficient information and other administrative requirements
• Refer service requests for medical necessity determinations to a Peer Reviewer when medical necessity is not established
• Ensure complete documentation of review and determinations
• Conduct Health and Safety Reviews
• Submit pharmacy consultation documentation and document any concerns associated with the review.
• Discuss treatment progress and current clinical presentation with referring provider as needed to aid in medical necessity determination

Facilitate Development of the Provider Network :

Other duties as assigned.

KNOWLEDGE, SKILL & ABILITIES

QUALIFICATIONS & EDUCATION REQUIREMENTS

Master’s degree in a Human Services field. Two years of post-degree progressive experience and practice that is relevant to the clinical area for which they will be conducting the initial clinical review. Experience in a Utilization Management environment in Behavioral Healthcare is required for this employee.

Licensure / Certification Required :

Must possess a current, active, unrestricted professional license or certification from North Carolina in a Human Services field (such as Psychology, Social Work, Counseling, Marriage and Family Therapy, Addictions, etc.).

PHYSICAL REQUIREMENTS

RESIDENCY REQUIREMENT : This position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY :   Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.