Behavioral Health Utilization Management Reviewer

Key Responsibilities:

Utilization Management (85%)

• Review behavioral health service requests to determine medical necessity using established clinical guidelines.
• Screen inpatient and outpatient requests for Medical Director review and gather required clinical documentation.
• Communicate authorization decisions to providers and members and ensure required decision notices are sent.
• Document reviews, authorizations, and updates in the utilization management system.
• Coordinate with health networks and customer service regarding member enrollment or coverage questions.
• Identify potential over- or under-utilization and escalate cases to the Medical Director when appropriate.
• Support care coordination and Transition Care Management (TCM) activities.
• Review ICD-10, CPT, and HCPCS codes for accuracy and coverage based on the line of business.
• Track and report member or provider complaints through the appropriate system.
  
  
  

Administrative Support (10%)

• Help identify staff training needs and assist with maintaining clinical or data resources.
• Follow required data tracking and documentation protocols.
  
  
  

Other Duties (5%)

• Assist with additional departmental projects as needed.
  
  
  

Minimum Qualifications:

• Current, unrestricted California license in one of the following: LCSW, LMFT, LPCC, or RN
• 3 years of clinical experience
• Utilization management reviewer experience
• Equivalent combinations of education and experience may also be considered
  
  
  

Preferred Qualifications:

• Experience in managed care
• Behavioral health clinical experience
  
  
  

Skills & Abilities:

• Ability to work independently and exercise sound clinical judgment.
• Strong written and verbal communication skills.
• Ability to stay organized and manage multiple cases in a fast-paced environment.
• Strong analytical and problem-solving abilities.
• Comfortable collaborating with clinical teams, providers, and internal departments.
• Proficiency with Microsoft Office and clinical/authorization systems.
  
  
  

Equal Opportunity Employer / Disabled / Protected Veterans

The Know Your Rights poster is available here:

https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12.pdf

The pay transparency policy is available here:

https://www.dol.gov/sites/dolgov/files/ofccp/pdf/pay-transp_ English_formattedESQA508c.pdf

For temporary assignments lasting 13 weeks or longer, the Company is pleased to offer major medical, dental, vision, 401k and any statutory sick pay where required.

We are committed to working with and providing reasonable accommodations to individuals with disabilities. If you need a reasonable accommodation for any part of the employment process, please contact your staffing representative who will reach out to our HR team.

ALL's WELL participates in the E-Verify program in certain locations as required by law. Learn more about the E-Verify program.

https://e-verify.uscis.gov/web/media/resourcesContents/E-Verify_Participation_Poster_ES.pdf

We also consider for employment qualified applicants regardless of criminal histories, consistent with legal requirements, including, if applicable, the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance. Pursuant to applicable state and municipal Fair Chance Laws and Ordinances, we will consider for employment-qualified applicants with arrest and conviction records, including, if applicable, the San Francisco Fair Chance Ordinance. For Los Angeles, CA applicants: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.

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