Responsibilities: The Utilization Management Clinical Consultant (UMCC) applies clinical expertise and evidence-based criteria to assess the medical necessity, appropriateness, and quality of behavioral health services for adult and child/adolescent members. Coordinate and communicate with healthcare providers, internal teams, and external stakeholders to facilitate timely, appropriate care and authorization decisions.
Numbers & Facts
Location
RI (Remote)
Description
Our Client, a Retail Pharmacy company, is looking for a Healthcare Consultant III - Utilization Management Clinical Consultant - Behavioral Health for their Remote location.
Responsibilities:
The Utilization Management Clinical Consultant (UMCC) applies clinical expertise and evidence-based criteria to assess the medical necessity, appropriateness, and quality of behavioral health services for adult and child/adolescent members. This role supports appropriate utilization of benefits across the continuum of care through collaboration, clinical review, and stakeholder communication.
Review clinical information and apply medical necessity criteria, clinical guidelines, policies, and professional judgment to render coverage determinations and discharge planning decisions.
Analyze medical records and clinical data to ensure services align with evidence-based standards and quality benchmarks.
Coordinate and communicate with healthcare providers, internal teams, and external stakeholders to facilitate timely, appropriate care and authorization decisions.
Conduct concurrent reviews to monitor ongoing inpatient or outpatient treatment and support continuity of care.
Identify members who may benefit from care management programs and facilitate appropriate referrals.
Provide urgent or emergent clinical interventions when required, including triage and crisis support.
Identify opportunities to optimize resource utilization, reduce unnecessary services, and promote cost-effective, high-quality care.
Educate providers, under appropriate supervision, on utilization management processes, documentation requirements, and applicable guidelines.
Develop and support initiatives that enhance quality effectiveness and benefit utilization.
Prepare clinical reports and documentation to communicate findings, monitor key performance indicators, and track utilization management outcomes.
Requirements:
Working knowledge of behavioral health terminology, clinical documentation, and utilization management principles.
Strong critical thinking, problem-solving, and decision-making skills.
Ability to evaluate clinical needs while balancing quality, cost, and member-centered care.
Effective communication skills with diverse clinical staff, members, and community partners.
Ability to handle sensitive and confidential information ethically and responsibly.
Digital literacy and ability to function effectively in a virtual, desk-based work environment.
Cultural competence and ability to work with diverse populations and interdisciplinary teams.
Master's degree required for behavioral health clinicians (LCSW, LPC, LMFT).