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Clinical Care Reviewer II – Behavioral Health, Prefer MA Licensed
CareSource. Process medical necessity reviews for authorization appropriateness of behavioral health care services .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Behavioral Health Care Services, including medical necessity reviews, care coordination, and discharge planning. Holds relevant clinical licensure and certifications while maintaining compliance with state and federal regulations.
Highest-signal resume keywords
Registered Nurse (RN) LicensureLicensed Clinical Social Worker (LCSW)MCG CertificationUtilization Management ExperienceBehavioral Health Services Review
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ExperienceData Entry SkillsBehavioral Health Care CoordinationDischarge PlanningProspective ReviewConcurrent ReviewRetrospective ReviewQuality Improvement IdentificationCare Management ReferralRegulatory Knowledge
Soft Skills
Effective CommunicationAttention to DetailTime ManagementProblem SolvingOrganizational Skills
Tools & Technologies
Microsoft OutlookMicrosoft WordMicrosoft ExcelClinical Platforms
Certifications & Qualifications
MCG Certification
Industry Keywords
MedicaidMedicareCommercial InsuranceProvider AgreementsAccreditation Standards
About the role
Key responsibilities & impact- Process medical necessity reviews for authorization appropriateness 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 to 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
- 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
- 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
Benefits
Comp & perks- Bonus tied to company and individual performance
- Substantial and comprehensive total rewards package
- Employee total well-being support