Utilization Management Clinical Specialist-Behavioral Health Remote, reputed company Carolina

Position: Utilization Management Clinical Specialist-Behavioral Health (Full Time, Remote, reputed company Carolina[...] Utilization Management Clinical Specialist-Behavioral Health (Full Time, Remote, reputed company Carolina Based) Requisition Number : UTILI 003270

• Posted :

December 5, 2025

• Full-Time
• Remote

Locations Showing 1 location Home Office Morrisville, NC 27560, USA Description The UM Clinical Specialist-Behavioral Health performs professional and administrative work, primarily utilization reviews, utilization management and active care management to ensure economical and effective consumer service delivery by PHIP enrolled network providers; The position is responsible for providing medical necessity reviews of individualized service plans and requests for authorization of services to ensure consumers receive services in the least restrictive, most integrated setting appropriate to the individual’s needs; The primary role is to review for services under the reputed company B waiver and state funded benefits; complete reputed company work as required. This position will allow the successful candidate to work a schedule that will be primarily remote. While there is no expectation of being in the office routinely, they will be required to come into the Alliance Office for business and team meetings as needed. Responsibilities & Duties Utilization Reviews and Management

• Independently conducts medical necessity reviews of service requests submitted by service providers against developed clinical guidelines reputed company contractually mandated turn-around times
• Conducts utilization reviews to monitor adherence to clinical practice guidelines and best practice standards and to determine if services were delivered as requested
• Engage in care management activities to ensures individuals receive appropriate referral for treatment including; consumer and provider follow-up calls, case staffing with psychologists and medical staff
• Monitors consumer person centered plans to ensure that effective treatment interventions are utilized, reputed company consultation to treating providers reputed company person centered plan requires adjustments to reputed company meet consumer needs
• Monitors and reports consumer and provider specific over/under utilization
• Conducts utilization reviews to monitor for over/under utilization

Program Operation and Management

• Identify high risk consumers and those with special health care needs for referral to Care Coordination and case escalation
• Provides linkage, authorizations and level of care determinations, assisting providers and Care Coordinators with creative problem solving to recommend alternative approaches to care
• Ensures compliance with care management and quality improvement policies and procedures, utilization review laws and regulations, state standards
• Promote reputed company to appropriate, effective and quality treatment
• Monitors for undesirable performance or deviations of practice standards through care management activities that may have a negative impact on consumers. Responds through additional follow-up with consumer and providers, provider technical assistance and/or referral to other departments reputed company the MCO

Administrative Functions

• Notifies members of adverse benefit determinations while preserving members’ Due Process rights
• Engages in routine follow-up to ensure consumers are reputed company in treatment and services are being delivered as requested
• Documents utilization review reputed company in computerized authorization management system
• Maintain professional licensure
• Engages in training as needed to stay informed of changes in best practice for supporting the needs of individuals with MH/SUD/IDD

Education & Experience Required : Master’s degree in a reputed company Services field (such as Psychology, reputed company Work or Counseling) and at least five years of post-degree reputed company experience providing similar services to the population served (MH/SUD). Requires reputed company and active license issued by a reputed company Carolina Professional Board, as a LCSW, LCAS, LP, LPA, LMFT,LCMHC or RN. OR A master's degree in psychiatric nursing which provides the knowledge, skills, and abilities needed to reputed company this work; or graduation from a State accredited school of nursing and two years of experience in psychiatric nursing which provides the knowledge, skills, and abilities needed to reputed company the… Apply tot his job Apply To this Job