Healthcare Consultant III

Job Summary:

• The Utilization Management Clinical Consultant (UMCC) applies clinical expertise and evidence-based criteria to assess the medical necessity, appropriateness, and quality of behavioral health services for adult and child/adolescent members.
• This role supports appropriate utilization of benefits across the continuum of care through collaboration, clinical review, and stakeholder communication.

Duties:

• Review clinical information and apply medical necessity criteria, clinical guidelines, policies, and professional judgment to render coverage determinations and discharge planning decisions.
• Analyze medical records and clinical data to ensure services align with evidence-based standards and quality benchmarks.
• Coordinate and communicate with healthcare providers, internal teams, and external stakeholders to facilitate timely, appropriate care and authorization decisions.
• Conduct concurrent reviews to monitor ongoing inpatient or outpatient treatment and support continuity of care.
• Identify members who may benefit from care management programs and facilitate appropriate referrals.
• Provide urgent or emergent clinical interventions when required, including triage and crisis support.
• Identify opportunities to optimize resource utilization, reduce unnecessary services, and promote cost-effective, high-quality care.
• Educate providers, under appropriate supervision, on utilization management processes, documentation requirements, and applicable guidelines.
• Develop and support initiatives that enhance quality effectiveness and benefit utilization.
• Prepare clinical reports and documentation to communicate findings, monitor key performance indicators, and track utilization management outcomes.

Education:

• Master’s degree required for behavioral health clinicians (LCSW, LPC, LMFT).
• Associate’s degree required for RN applicants.

Knowledge, Skills and Abilities:

• Working knowledge of behavioral health terminology, clinical documentation, and utilization management principles.
• Strong critical thinking, problem-solving, and decision-making skills.
• Ability to evaluate clinical needs while balancing quality, cost, and member-centered care.
• Effective communication skills with diverse clinical staff, members, and community partners.
• Ability to handle sensitive and confidential information ethically and responsibly.
• Digital literacy and ability to function effectively in a virtual, desk-based work environment.
• Cultural competence and ability to work with diverse populations and interdisciplinary teams.

Top 3 Skills:

Behavioral Health Utilization Management:

• Ability to review clinical information, apply medical necessity guidelines, and make UM decisions (initial, concurrent, and discharge planning).
• Includes strong discharge planning skills to support safe, appropriate transitions of care.

Clinical Assessment & Critical Thinking:

• Skilled in evaluating clinical needs, reviewing records, and making sound decisions that balance quality, cost, and member-centered care.
• Must have a strong understanding of community behavioral health resources to support referrals and continuity of care.

Communication & Coordination:

• Strong communication skills with providers and internal teams, plus accurate documentation and strong organizational skills.
• Ability to coordinate effectively across multiple stakeholders to support timely care and utilization decisions.

Work Environment:

• Primarily sedentary, desk-based role involving extended periods of sitting, talking, and focused review work.