Utilization Management Clinical Specialist-Behavioral Health Remote, North Carolina

Position: Utilization Management Clinical Specialist-Behavioral Health (Full Time, Remote, North Carolina[...] Utilization Management Clinical Specialist-Behavioral Health (Full Time, Remote, North 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 Medicaid B waiver and state funded benefits; complete related 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 within 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, provide consultation to treating providers when person centered plan requires adjustments to better 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 access 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 within 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 engaged in treatment and services are being delivered as requested • Documents utilization review decisions 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 Human Services field (such as Psychology, Social Work or Counseling) and at least five years of post-degree progressive experience providing similar services to the population served (MH/SUD). Requires current and active license issued by a North 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 perform 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 perform the… Apply tot his job