Responsibilities:

Under the direction of the Supervisor, the BH UM Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and experience, the clinician reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the BH UM Reviewer’s discretion to retain requests for additional information and/or request clarification. The BH UM Reviewer will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases to integrated care management as needed. The BH UM Reviewer will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when indicated. The BH UM Reviewers are responsible to ensure that treatment delivered is appropriately utilized and meets the member’s needs in the least restrictive, least intrusive manner possible. The BH UM Reviewer will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and uses clinical judgment in their application.

Education/Experience:

• Registered Nurse.
• LCSW, LMSW, LPC, LMFT.
• Registered Nurse graduate from an accredited institution with an Associate Degree or Bachelor’s Degree. Master’s Degree preferred. Mental Health and/or Substance Use Disorder experience requirement.
• Or LCSW, LMSW, LPC, LMFT independent, current and unrestricted licensure with a Master’s Degree preferred. Graduate degree in social work/mental health profession. The degree must be from an accredited institution and the individual must have completed a supervised field experience in case management, health or behavioral health as part of the degree requirements.
• Three (3) to five (5) years Behavioral Health experience.