Job Summary
The Behavioral Health Clinical Reviewer is responsible for conducting administrative and process-based reviews of medical records to ensure compliance with medical necessity criteria, regulatory guidelines, and contractual requirements. This role evaluates behavioral health services for accuracy, appropriateness, and completeness. This is a non-direct care position requiring strong clinical expertise in behavioral health.
Key Responsibilities
- Conduct prospective, concurrent, and retrospective reviews of behavioral health services
- Evaluate medical records to determine medical necessity and adherence to established guidelines
- Ensure accuracy, quality, and timeliness of all reviews
- Manage daily workload and review queues to meet productivity standards
- Collaborate with internal teams on quality improvement initiatives
- Serve as a liaison for providers, addressing inquiries and resolving service-related issues
- Maintain current knowledge of behavioral health practices, policies, and review criteria
- Participate in team meetings and ongoing training
- Ensure compliance with HIPAA and all organizational policies
Required Qualifications
- Active, unrestricted Arkansas license in good standing in one of the following:
- LCSW, LMSW
- LAMFT, LMFT
- LAC, LPC
- LPE, LPE-I
- Master’s degree in Behavioral Health or a related field from an accredited institution
- Minimum of 2+ years of experience in a behavioral health setting, including utilization review or case management
- Strong knowledge of medical, psychiatric, and psychological terminology
- Experience reviewing mental health assessments and treatment plans
- Understanding of behavioral health services across inpatient and outpatient settings
- Ability to handle confidential HIPAA information with discretion
- Strong interpersonal, organizational, and communication skills
- Ability to collaborate effectively with providers and stakeholders
Preferred Qualifications
- Experience working with child and adolescent populations
- Experience in Utilization Review (UR) or Utilization Management (UM)
- Clinical quality review and medical record evaluation experience
- Familiarity with Arkansas Medicaid medical necessity criteria
- Knowledge of Arkansas Medicaid behavioral health policies and procedures
- Proficiency with automated review systems and Microsoft Office Suite
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