UM Clinical Specialist-Behavioral Health (Full-time Remote, North Carolina Based)

UM Clinical Specialist-Behavioral Health (Full-time Remote, North Carolina Based) Posted on May 8, 2026 Location: Remote in North Carolina, USA 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 is full-time remote. The selected candidate must reside in North Carolina. Some travel for onsite meetings may be required. Responsibilities & Duties Independently conduct medical necessity reviews of service requests submitted by service providers against developed clinical guidelines within contractually mandated turn‑around times. Conduct 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 ensure individuals receive appropriate referral for treatment, including consumer and provider follow‑up calls, case staffing with psychologists and medical staff. Monitor consumer person‑centered plans to ensure effective treatment interventions are utilized and provide consultation to treating providers when the plan requires adjustments. Monitor and report consumer and provider specific over/under utilization. Identify high‑risk consumers and those with special health care needs for referral to Care Coordination and case escalation. Provide linkage, authorizations and level of care determinations, assisting providers and Care Coordinators with creative problem solving to recommend alternative approaches to care. Ensure 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. Respond to undesirable performance or deviations from practice standards through additional follow‑up with consumers and providers, provider technical assistance and/or referral to other departments within the MCO. Notify members of adverse benefit determinations while preserving due‑process rights. Engage in routine follow‑up to ensure consumers are engaged in treatment and services are being delivered as requested. Document utilization review decisions in a computerized authorization management system. Maintain professional licensure and engage in training as needed to stay informed of changes in best practice for supporting the needs of individuals with mental health, substance use, and intellectual or developmental disabilities. Education & Experience Required: Master’s degree in a Human Services field (e.g., Psychology, Social Work, Counseling) and at least five years of progressive post‑degree experience providing similar services to the population served (mental health/substance use). Current & active North Carolina license (LCSW, LCAS, LP, LPA, LMFT, LCMHC, RN) required. OR: Master’s degree in psychiatric nursing or graduation from a state‑accredited school of nursing plus two years of experience in psychiatric nursing. Equivalent combinations of education and experience accepted. Preferred: Experience in the public behavioral health care field; experience in a utilization management environment in behavioral health valued. Knowledge, Skills & Abilities Considerable knowledge of case management principles, practices and applications. Knowledge of agency and community programs and services affecting clients. Knowledge of state and federal client rights protection statutes and regulations, including URAC, Code of Federal Regulations, NC Administrative Code. Effective written and oral communication skills, interpersonal and presentation skills. Ability to identify rights protection complaint issues; set, monitor and evaluate standards for quality and assess plans to meet client needs. Knowledge of DMS 5 diagnostic criteria. Ability to manage time, prioritize work and apply problem‑solving approaches. Ability to coordinate effectively with staff from various agencies and inter‑departmental teams. Ability to read, analyze, and interpret regulations, policies and procedures. Ability to operate computer equipment and generate reports; express ideas clearly orally and in written documents. Proficiency in Microsoft Office products (Word, Excel, Outlook, etc.) required. Salary & Benefits Salary Range: $68,227 – $86,990 annually. Exact compensation based on education, experience, market data and internal equity. An excellent fringe benefit package accompanies the salary, including: Generous retirement savings plan. Flexible work schedules, including hybrid/remote options. Paid time off: vacation, sick leave, holiday, management leave. Dress flexibility. Equal Opportunity Employer This employer complies with federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor. #J-18808-Ljbffr Alliance