Clinical Care Reviewer II – Behavioral Health

CareSource

. Process medical necessity reviews for authorization of behavioral health care services .

Posted 10/28/2026full-timeRemote • Massachusetts • United StatesMid-LevelSenior💰 $62,700 - $100,400 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in processing medical necessity reviews and coordinating care for behavioral health services, while maintaining compliance with state and federal regulations. Proficient in data entry and clinical platform navigation, with strong communication and organizational skills.

Highest-signal resume keywords

Clinical ExperienceUtilization ManagementRegistered Nurse (RN) LicensureMCG CertificationBehavioral Health Services Coordination

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity ReviewsDischarge PlanningProspective ReviewsConcurrent ReviewsRetrospective ReviewsData Entry SkillsClinical Platform NavigationAttention to DetailTime ManagementProblem Solving

Soft Skills

Effective CommunicationCustomer Service OrientationOrganizational SkillsChange ResiliencyTeam Collaboration

Tools & Technologies

Microsoft OutlookMicrosoft WordMicrosoft Excel

Certifications & Qualifications

Registered Nurse (RN) LicensureLicensed Social Worker (LSW)Licensed Clinical Social Worker (LCSW)Licensed Independent Clinical Social Worker (LICSW)Associate Clinical Social Worker (ACSW)Licensed Mental Health Counselor (LMHC)Licensed Professional Counselor (LPC)Licensed Marriage & Family Therapist (LMFT)Licensed Mental Health Practitioner (LMHP)MCG Certification

Industry Keywords

Behavioral Health Care ServicesMedicaidMedicareUtilization ReviewQuality ImprovementCare ManagementState ContractsProvider AgreementsAccreditation Standards

About the role

Key responsibilities & impact

Process medical necessity reviews for authorization of behavioral health care services
Assist with discharge planning activities, including outpatient services and home health services
Coordinate care for members
Complete prospective, concurrent, and retrospective reviews of Behavioral Health services
Identify, document, communicate, and coordinate care with collaborative care partners to facilitate transition to an appropriate level of care
Engage with the medical director when additional clinical expertise is needed
Maintain knowledge of state and federal regulations, State Contracts, Provider Agreements, benefits, and accreditation standards
Identify and refer quality issues to Quality Improvement
Identify and refer appropriate members for Care Management
Provide guidance to non-clinical staff and support LPN staff
Attend medical advisement and State Hearing meetings as requested
Assist the Team Leader with special projects or research as requested
Perform other job-related duties as requested

Requirements

What you’ll need

Associates of Science (A.S) in Nursing required, or Bachelor of Science (B.S) in Social Work required, or Master's degree in a mental health related field required
Three (3) years clinical experience required
Utilization Management/Utilization Review experience preferred
Medicaid/Medicare/Commercial experience preferred
Proficient data entry skills and ability to navigate clinical platforms successfully
Working knowledge of Microsoft Outlook, Word, and Excel
Effective oral and written communication skills
Ability to work independently and within a team environment
Attention to detail
Proper grammar usage and phone etiquette
Time management and prioritization skills
Customer service oriented
Decision making/problem solving skills
Strong organizational skills
Change resiliency
Current, unrestricted Registered Nurse (RN) Licensure, Licensed Social Worker (LSW, Licensed Clinical Social Worker (LCSW), Licensed Independent Clinical Social Worker (LICSW), Associate Clinical Social Worker (ACSW), Licensed Mental Health Counselor (LMHC), Licensed Professional Counselor (LPC), Licensed Marriage & Family Therapist (LMFT) or Licensed Mental Health Practitioner (LMHP) required
MCG Certification is required or must be obtained within six (6) months of hire

Benefits

Comp & perks

Potential bonus tied to company and individual performance
Substantial and comprehensive total rewards package
Remote work arrangement