Healthcare Consultant III

Mercy Care is a not-for-profit Medicaid managed care organization serving Arizona since 1985. Mercy Care is administered by Healthcare, a *** company, providing access to the resources of a national organization while maintaining strong local community engagement.
Primary Duties & Responsibilities:
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.
Primarily sedentary, desk-based role involving extended periods of sitting, talking, and focused review work.
Standard schedule: MondayFriday, 8:00 AM5:00 PM Arizona time.
Occasional holiday or weekend coverage required through rotation.

***Question Candidate Questionnaire - Attach at Top of Resume along with screenshots of active licenses***
1. Do you have experience performing behavioral health utilization management or clinical reviews?
Yes / No If yes how many years?
2. Have you used medical necessity criteria such as InterQual, MCG, ASAM, or LOCUS?
Yes / No If yes which ones?
3. Which populations do you have clinical experience with?
Adults
Child/Adolescent
Both
4.Do you have experience communicating with providers or clinical teams regarding authorizations or care coordination? Yes / No If yes briefly describe.
5. Can you work MondayFriday, 8am5pm Arizona time, are you open to occasional holiday/weekend rotation? And do you have a private, quiet workspace suitable for confidential review work?
Yes / No
6.Attach internet speed
7. Must have an active Client (LCSW Licensed Clinical Social Worker OR LPC Licensed Professional Counselor OR LMFT Licensed Marriage and Family Therapist) OR will consider RNs with an active compact license who focus in BH

Top 3 Skills
1. 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.

2. 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.

3. 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.

SAFETY

Timeline:
-Interview Period: February 23 March 6
-All Offers Out and Accepted By: March 11
-Candidates Fully Cleared By: March 27
-Targeted Start Date for Hires: April 13

Position 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:

Primary Duties & Responsibilities:
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.

Experience:

Essential Qualifications:
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.

Work Environment & Schedule
Primarily sedentary, desk-based role involving extended periods of sitting, talking, and focused review work.
Standard schedule: MondayFriday, 8:00 AM5:00 PM Arizona time.
Occasional holiday or weekend coverage required through rotation.

Education:

Masters degree required for behavioral health clinicians (LCSW, LPC, LMFT).
Associates degree required for RN applicants.