Job Description
The Behavioral Health Utilization Review Specialist conducts comprehensive utilization management activities for behavioral health plan members. This role includes coordinating services for members in crisis, performing crisis intervention, conducting behavioral health triage and assessments, pre-certification and authorization of psychiatric and chemical dependency services, and engaging in concurrent review with hospitals and mental health centers. The specialist is responsible for planning discharges and aftercare, and referring members for continued outpatient care.
ResponsibilitiesReview prior authorization requests for medical necessity and appropriateness using standardized criteria.Coordinate with the Medical Director/Physicians for requests outside of standard criteria.Interact with hospital representatives and attending psychiatrists, and coordinate physician-to-physician reviews.Review treatment plans and consult with the Medical Director regarding medical necessity criteria for continued inpatient stay.Facilitate community placements, agency linkages, and coordinate discharge planning, aftercare, referral, and follow-up of inpatients.Maintain compliance with federal and state guidelines and contractual requirements.Obtain necessary documentation and ensure completion of assigned caseload by addressing discrepancies.Serve as a liaison between the Medical Director, physicians, and office staff to resolve prior authorization issues.Perform evaluation and concurrent monitoring of appropriate utilization of resources such as hospitalizations and outpatient services.Provide current and timely documentation reflecting department work processes and policy guidelines.Promote safe and appropriate coordination of care and optimal utilization of resources.Identify and participate in the development of programs, policies, and procedures for continuous quality improvement.Assure adherence to company and department policies regarding confidentiality.Participate in regular departmental training.Serve as a plan liaison to coordinate enrollee benefits with providers and external organizations.Prepare and present reports on department activities as assigned.Essential SkillsProficiency in clinical review and utilization management.Knowledge of Interqual and Milliman Commercial Guidelines.Understanding of Medicaid, Medicare, and managed care.Experience in patient care and medical record management.Additional Skills & QualificationsDegree in nursing or a related field in behavioral health.Current unrestricted Florida License (RN, or LMHC).Minimum of two years of experience in utilization review/case management.At least one year of experience in discharge planning within an acute care setting is highly desirable.Work Environment
This position offers a hybrid work schedule, with in-office work required in Sunrise on Tuesdays from 8:30 AM to 5:00 PM, including a 30-minute lunch break. Training will take between 2-4 weeks, during which you will shadow a team member on-site and through Teams on other days.
Pay and Benefits
The pay range for this position is $35.00 - $38.00/hr.
Eligibility requirements apply to some benefits and may depend on your job
classification and length of employment. Benefits are subject to change and may be
subject to specific elections, plan, or program terms. If eligible, the benefits
available for this temporary role may include the following:
• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)
Workplace Type
This is a hybrid position in Sunrise,FL.
Application Deadline
This position is anticipated to close on Jul 1, 2025.
About Actalent
Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.