UM Clinical Specialist – Behavioral Health

Alliance Health

. Conduct medical necessity reviews of service requests against clinical guidelines within contractually mandated turnaround times .

Posted 10/31/2026full-timeNorth Carolina • United StatesMid-LevelSenior💰 $69,592 - $88,729 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in conducting medical necessity and utilization reviews while ensuring compliance with clinical guidelines and state regulations. Proficient in care management activities, including case staffing and consumer follow-up, with a strong focus on quality improvement and problem-solving.

Highest-signal resume keywords

Medical Necessity ReviewsUtilization ReviewsCare ManagementClinical Guidelines ComplianceLicensed Clinical Professional

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Case Management PrinciplesQuality ImprovementDSM-5-TR Diagnostic CriteriaTime ManagementProblem-Solving Approaches

Soft Skills

Effective CommunicationInterpersonal SkillsPresentation Skills

Tools & Technologies

Computerized Authorization Management SystemMicrosoft Office Suite

Certifications & Qualifications

North Carolina Professional LicenseLCSWLCASLPLPALMFTLCMHCRN

Industry Keywords

Mental HealthSubstance Use DisorderIntellectual and Developmental DisabilitiesClient Rights ProtectionURAC Compliance

About the role

Key responsibilities & impact

Conduct medical necessity reviews of service requests against clinical guidelines within contractually mandated turnaround times
Conduct utilization reviews to monitor adherence to clinical practice guidelines and best-practice standards
Engage in care management activities, including consumer and provider follow-up calls and case staffing with psychologists and medical staff
Monitor person-centered plans and consult with treating providers when adjustments are needed
Monitor and report consumer- and provider-specific over/under utilization
Identify high-risk consumers and those with special healthcare needs for referral to Care Coordination and case escalation
Provide linkage, authorizations, and level-of-care determinations
Assist providers and Care Coordinators with creative problem solving and alternative approaches to care
Ensure compliance with care management, quality improvement, utilization review laws and regulations, and state standards
Monitor undesirable performance or deviations from practice standards and respond through follow-up, technical assistance, or referral
Notify members of adverse benefit determinations while preserving Due Process rights
Document utilization review decisions in a computerized authorization management system
Engage in training to stay informed about best practices for individuals with MH/SUD/IDD

Requirements

What you’ll need

Master’s degree in a Human Services field such as Psychology, Social Work or Counseling and at least five (5) years of post-degree clinical experience providing similar services to the population served (MH/SUD)
OR Master’s degree in Psychiatric Nursing and five (5) years of experience in psychiatric nursing
OR Bachelor of Science in Nursing and five (5) years of experience in psychiatric nursing
Current and active license issued by a North Carolina Professional Board, such as LCSW, LCAS, LP, LPA, LMFT, LCMHC, or RN
Knowledge of case management principles, practices and applications
Knowledge of agency and community programs and services
Knowledge of state and federal client rights protection statutes and regulations, URAC, applicable Code of Federal Regulations and NC Administrative Code
Effective written and oral communication, interpersonal and presentation skills
Ability to identify rights protection complaint issues and evaluate quality standards
Knowledge of DSM-5-TR diagnostic criteria
Ability to manage time, prioritize work and use problem-solving approaches
Ability to coordinate with staff from various agencies and departments
Ability to read, analyze, and interpret regulations, policies and procedures
Ability to operate computer equipment and generate reports and records
Proficiency in Microsoft Office products such as Word, Excel, and Outlook
Maintain professional licensure

Benefits

Comp & perks

Medical, Dental, Vision, Life, Long Term Disability
Generous retirement savings plan
Flexible work schedules including hybrid/remote options
Paid time off including vacation, sick leave, holiday, management leave
Dress flexibility