Behavioral Health Clinical Review Manager

Utilization Management role focused on behavioral health and withdrawal management, involving care decision shaping and outcome improvement without face-to-face interaction.

Location: Tennessee, USA

Responsibilities

• Assists non-clinical staff in performance of administrative reviews
• Initiate referrals to ensure appropriate coordination of care
• Seek the advice of the Medical Director when appropriate, according to policy
• Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility

Requirements

• Current, active unrestricted Tennessee license in Nursing (RN) or behavioral health field (Master's level or above) (Ph.D., LCSW/LMSW, LLP, MHC, LPC, etc.) required
• 3 years - Clinical behavioral health / substance use disorder experience required
• Must be knowledgeable about community care resources and levels of behavioral health care available
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Independent, Sound decision-making and problem-solving skills
• Excellent oral and written communication skills
• Strong interpersonal and organizational skills
• Strong analytical skills
• Positive relationship building skills and ability to engage with diverse populations
• Ability to quickly identify and prioritize member needs and provide structured and focused support and interventions