• Behavioral Health Outpatient Reviewer

    Job Location US-MI-Detroit
    Job ID
    Utilization Management
    Business Line
    CMC Corporate
  • Overview

    Who we are:

    Meridian, a WellCare Company, is part of a national network of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry.


    We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in Michigan, Illinois, Indiana, and Ohio. As a part of the WellCare Family of companies, we deliver healthcare excellence to millions of members nationwide.


    Our associates work hard, play hard, and give back. Meridian associates enjoy an exceptional experience and culture including special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities.


    A Day in the Life of a Behavioral Health Outpatient Reviewer:

    This position is responsible for obtaining, processing and communicating clinical information for the purpose of providing determination of all applicable behavioral health and substance abuse requests.


    ·         Completes behavioral health and substance abuse utilization reviews for all applicable lines of business.

    • Performs initial medical necessity screening and concurrent review on utilization management functions as assigned
    • Demonstrate consistent ability to collect pertinent documentation and conduct psychiatric and substance abuse reviews by applying appropriate criteria, which may include national standardized criteria, local plan rules and guidelines, benefit certificates and other resources as indicated, while at the same time utilizing sound clinical judgement
    • Identifies appropriate benefits, eligibility and expected length of stay for members requesting treatments and/or procedures
    • Ensures that all decisions (approvals, denials and/or requests for additional information) are provided to the servicing provider within established timeframes
    • Contacts hospitals, physicians or ancillary providers where additional information is necessary to make a decision
    • Consults with Medical Director as appropriate for all requests requiring MD approval or not meeting criteria for approval
    • Shares team clinical after hours duties as assigned
    • Consistently demonstrates compliance with HIPAA regulations, professional conduct and ethical practice
    • Collaborates with Behavioral Health Medical Director for requests not meeting medical necessity guidelines
    • Prepares denial letters for denied inpatient psychiatric admission
    • Prepares benefit exhaust letters for applicable levels of care
    • Participates in interdepartmental integration and collaboration to enhance continuity of care for members
    • Participate in discharge planning of members with psychiatric disorders to support MHP outreach efforts to improve Healthcare Effectiveness Data Information Set (HEDIS) measures and Provider Services Network Activities
    • Obtains all required clinical information according to established timeframe standards throughout the hospitalization to obtain certification approval for all services provided
    • Maintains a collaborative working with relationship with the servicing facilities utilization review nurses and case managers and maintains contact regarding initial assessment, progress, changes in condition, discharge planning, discharge date, etc.
    • Follow appropriate NCQA and State-specific regulations, as conducted by Utilization Management staff


    What you can bring to Meridian:

    • Current license to practice as a Registered Nurse in the designated State, without restriction, is required
    • Bachelor’s degree in nursing, allied health, business or related field is preferred
    • Utilization Review background in either Managed Care or Provider environment

    • Experience in patient, skilled nurses facilities, rehab, and home healthcare

    • Minimum of 2-4 years of clinical practice. Preferably hospital nursing, utilization management, and/or case management

    What Meridian can offer you:

    • Our healthcare benefits include a variety of plans that are effective on the first day of employment for our new full-time team members.
    • Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.
    • Meridian offers 401k matching that is above the national average.
    • Full-time Meridian employees are eligible for tuition reimbursement towards Bachelor’s or Master’s degrees.
    • Meridian was named Detroit's #1 Fastest Growing Company by Crain's Magazine, so it is a great time to get involved with Meridian.


    Equal Opportunity Employer



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