Job Title: Behavioral Health Utilization Review Specialist

Job Description

The Behavioral Health Utilization Review Specialist conducts comprehensive utilization management activities for behavioral health plan members. This role includes coordinating services for members in crisis, performing crisis intervention, conducting behavioral health triage and assessments, pre-certification and authorization of psychiatric and chemical dependency services, and engaging in concurrent review with hospitals and mental health centers. The specialist is responsible for planning discharges and aftercare, and referring members for continued outpatient care.

Responsibilities

• Review prior authorization requests for medical necessity and appropriateness using standardized criteria.
• Coordinate with the Medical Director/Physicians for requests outside of standard criteria.
• Interact with hospital representatives and attending psychiatrists, and coordinate physician-to-physician reviews.
• Review treatment plans and consult with the Medical Director regarding medical necessity criteria for continued inpatient stay.
• Facilitate community placements, agency linkages, and coordinate discharge planning, aftercare, referral, and follow-up of inpatients.
• Maintain compliance with federal and state guidelines and contractual requirements.
• Obtain necessary documentation and ensure completion of assigned caseload by addressing discrepancies.
• Serve as a liaison between the Medical Director, physicians, and office staff to resolve prior authorization issues.
• Perform evaluation and concurrent monitoring of appropriate utilization of resources such as hospitalizations and outpatient services.
• Provide current and timely documentation reflecting department work processes and policy guidelines.
• Promote safe and appropriate coordination of care and optimal utilization of resources.
• Identify and participate in the development of programs, policies, and procedures for continuous quality improvement.
• Assure adherence to company and department policies regarding confidentiality.
• Participate in regular departmental training.
• Serve as a plan liaison to coordinate enrollee benefits with providers and external organizations.
• Prepare and present reports on department activities as assigned.

Essential Skills

• Proficiency in clinical review and utilization management.
• Knowledge of Interqual and Milliman Commercial Guidelines.
• Understanding of Medicaid, Medicare, and managed care.
• Experience in patient care and medical record management.

Additional Skills & Qualifications

• Degree in nursing or a related field in behavioral health.
• Current unrestricted Florida License (RN, or LMHC).
• Minimum of two years of experience in utilization review/case management.
• At least one year of experience in discharge planning within an acute care setting is highly desirable.

Work Environment

This position offers a hybrid work schedule, with in-office work required in Sunrise on Tuesdays from 8:30 AM to 5:00 PM, including a 30-minute lunch break. Training will take between 2-4 weeks, during which you will shadow a team member on-site and through Teams on other days.