Responsible for reviewing clinical information from providers to ensure it meets Medical Necessity Criteria for authorizing behavioral health and substance use services. Ensures accurate data entry into claims systems for payment processing while adhering to regulatory and contractual requirements.
Requirements summary
Requires a Master's degree in Counseling, Social Work, or Marriage and Family Therapy (or a BSN for RNs) and a valid state license (LCSW, LPC, LMFT, or RN). Candidates must have at least 2 years of behavioral health experience and 1 year of case management experience.
bachelor degreepostgraduate degreeprofessional certificateCase ManagementRegulatory ComplianceCare CoordinationClinical DocumentationBehavioral HealthDischarge PlanningSubstance Use ServicesClinical ReviewUtilization ManagementMedical Necessity CriteriaDMAS ProtocolsContinuity Of Care
Job description
City/State Norfolk, VA Work Shift Weekend Days Overview
Sentara Health Plans is hiring a Behavioral Health Utilization Management Clinician/LCSW/LPC/LMFT/RN - Community Based - Flexible Weekend Dayshift - Remote in VA and NC!
Status:
Full-time, permanent position (40 hours)
Work hours: Flexible weekend dayshift; Can start from 6am to 9am
EST for a 4 x 10 hour shift (Thursday to
Sunday)
Location: Fully remote in Virginia OR Northeast North Carolina. Overview Behavioral Health Utilization Management clinician is responsible for review of clinical information received from providers ensuring clinical data is substantial enough to meet Medical Necessity Criteria to authorize services as needed. Requires knowledge of medical necessity criteria for behavioral health and substance use services, DMAS protocols, clinical protocols and clinical review requirements. Requires knowledge of contractual, regulatory and compliance requirements for government payers, self-funded and commercial payers. Ensures appropriate and accurate information is entered into claims system for processing of payment. Education Master’s degree in Counseling, Social Work, or Marriage and Family Therapy REQUIRED For Registered Nurses, a Bachelor of Science in nursing is REQUIRED Certification/Licensure REQUIRED license must be valid in state of practice.
One of the following qualifies: Licensed Clinical Social Worker (LCSW) - State license - Virginia Department of Health Professionals (VADHP) OR Licensed Clinical Social Worker (LCSW) - State license - North Carolina Social Work Certification and Licensure Board (NCSWCLB) OR Licensed Professional Counselor (LPC) - State license - Virginia Department of Health Professionals (VADHP) OR Licensed Professional Counselor (LPC) - State license - North Carolina Board of Licensed Clinical Mental Health Counselors (NCBLCMHC) OR Licensed Marriage and Family Therapist (LMFT) - State license - Virginia Department of Health Professionals (VADHP) OR Licensed Marriage and Family Therapist (LMFT) - State license - North Carolina Marriage and Family Therapy Licensure Board (NCBMFT) OR Registered Nurse (RN) Single State - Nursing License - Virginia Department of Health Professionals (VADHP) OR Registered Nurse (RN) Single State - Nursing License - North Carolina Board of Nursing (NCBON) OR Registered Nurse (RN) Multi State - Nursing License - Virginia Department of Health Professionals (VADHP) OR Registered Nurse (RN) Multi State - Nursing License - North Carolina Board of Nursing (NCBON) Licensed Substance Abuse Treatment Practitioner (LSATP) OR Certified Substance Abuse Counselor (CSAC) OR Licensed Chemical Dependency Counselors (LCDC) preferred Experience 2 years of behavioral health REQUIRED 1 year of case management REQUIRED Experience in community based mental health services highly preferred Utilization Management and Health plan experience preferred Sentara Health Plans provides health plan coverage to close to one million members in Virginia. We offer a full suite of commercial products including employee-owned and employer-sponsored plans, as well as Individual & Family Health Plans, Employee Assistance Programs and plans serving Medicare and Medicaid enrollees. Our quality provider network features a robust provider network, including specialists, primary care physicians and hospitals. We offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services—all to help our members improve their health. Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth. Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve! To apply, please go to www.sentaracareers.com and use the following as your
Benefits
Dental Insurance
Life Insurance
Sick Leave
Paid Time Off
Vision Insurance
Medical Insurance
Short-Term Disability
Long-Term Disability
Professional Development
Pet Insurance
Critical Illness Plans
Tuition Assistance
Certification Reimbursement
Paid Parental & Family Caregiver Leave
Emergency Backup Care
401k/403B with Employer Match
Student Debt Pay Down
Legal Resources Plan
Annual Discretionary Bonus
Adoption, Fertility and Surrogacy Reimbursement
Keyword
Search: JR-100250 Talroo – Health Plan Managed Care, MCO, Health Plan, Healthcare, Masters, Social Work, Counseling Field, BSN, Nursing, Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), Registered Nurse License (RN), Clinical, behavioral health, care coordination, discharge planning, continuity of care, transitions of care, Remote, Virginia, Weekends, Days, North Carolina, Utilization
Management,
UM,
Community
Based,
CSB,
Mental
Health
Benefits: Caring For Your Family and Your Career
Medical, Dental, Vision plans
Adoption, Fertility and Surrogacy Reimbursement up to $10,000
Paid Time Off and Sick Leave
Paid Parental & Family Caregiver Leave
Emergency Backup Care
Long-Term, Short-Term Disability, and Critical Illness plans
Life Insurance
401k/403B with Employer Match
Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
Student Debt Pay Down – $10,000
Reimbursement for certifications and free access to complete CEUs and professional development
Pet Insurance
Legal Resources Plan
Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met. Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves. In support of our mission “to improve health every day,” this is a tobacco-free environment. For positions that are available as remote work,
Sentara
Health employs associates in the following states: Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. Sentara Health is a Virginia and Northeastern North Carolina based not-for-profit integrated healthcare provider that has been in business for over 131 years. Offering hundreds of sites of care including 12 hospitals, PACE, home health, hospice, medical groups, imaging services, therapy, outpatient surgery centers, and an 858,000 member health plan. The people of the communities that we serve have nominated Sentara “Employer of Choice” for over ten years. U.S. News and World Report has recognized Sentara as having the Best Hospitals for 15+ years. Sentara offers professional development and a continued employment philosophy!
