Job Description
The Behavioral Health Physician UM Reviewer is responsible for conducting clinical reviews of behavioral health services to ensure medical necessity, appropriateness of care, and compliance with regulatory standards. This role collaborates closely with care management teams, providers, and payers to support effective utilization of behavioral health services and to promote high-quality, cost-effective treatment for members.
We are currently seeking someone with licensure in New York.
Key Responsibilities:
Review and evaluate behavioral health service requests for medical necessity based on evidence-based criteria (e.g., MCG, InterQual, ASAM).
Collaborate with clinical and non-clinical team members to support integrated care management.
Make determinations on service authorizations, denials, or the need for peer-to-peer discussions in alignment with organizational policies.
Participate in case conferences and interdepartmental rounds to support ongoing utilization management initiatives.
Ensure compliance with NCQA, URAC, CMS, and state/federal guidelines.
Provide clinical guidance and feedback to utilization review staff and care coordination teams.
Maintain documentation of all reviews and decisions in appropriate systems within required timeframes.
Support quality improvement initiatives and clinical policy development as needed.
Participate in audits and appeal processes related to utilization of review decisions.
Qualifications:
MD or DO with current, unrestricted license to practice medicine in New York.
Board certification in Psychiatry or Child and Adolescent Psychiatry (required).
Minimum 5 years of clinical experience in behavioral health settings.
At least 2 years of experience in utilization management, care review, or health plan operations (preferred).
Familiarity with utilization review criteria, regulatory standards, and managed care principles.
Strong decision-making, analytical, and interpersonal communication skills.
Proficiency in EMR and UM platforms (e.g., Jiva or similar systems).
Preferred Skills:
Experience with Medicaid, Medicare, or commercial insurance utilization review.
Knowledge of behavioral health treatment modalities including inpatient, outpatient, and substance use care.
Ability to work independently and as part of a multidisciplinary team.
Strong organizational and time management abilities.
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