Utilization Management Specialist (LCPC/LCSW-C)

Introduction:

The Behavioral Health Utilization Management Specialist will be responsible for performing prospective, concurrent, and retrospective reviews for authorization, appropriateness of care determination, and benefit coverage. Utilizing clinical expertise and critical thinking skills, the specialist will analyze clinical information, contracts, mandates, and medical policies to contribute to the determination of appropriateness and authorization of clinical services.

Responsibilities:

• Determine medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, and medical guidelines
• Conduct research and analysis of diseases, treatments, and emerging technologies to support decisions and recommendations
• Make appropriate referrals and contacts as needed and offer assistance to members and providers for alternative care settings
• Collaborate with medical directors, sales and marketing, contracting, and provider services to determine appropriate benefit application
• Research and present educational topics related to cases, disease entities, and treatment modalities

Requirements:

Certifications (one or both):
(1) LCPC - Licensed Clinical Professional Counselor - MD, DC, or VA license required
(2) LCSW-C - Licensed Clinical Social Worker - MD, DC, or VA license required

Required Education:
Education Level: Master's Degree
Education Details: Psychology or Social Work

Experience:
- 5 years Clinical experience required
- 2 years Care Management preferred
- Working knowledge of managed care and behavioral health delivery systems
- Experience in treatment of substance abuse and mental health treatment mandatory
- Thorough knowledge of clinical guidelines and medical policies
- Experience in direct treatment of substance use and mental health focused treatment
- Excellent MS Excel Skills
- Familiarity with ASAM, Medicare Guidelines, and other medical references