Job Summary
The Behavioral Health Clinical Reviewer is responsible for conducting administrative and process-based reviews of medical records to ensure compliance with medical necessity criteria, regulatory guidelines, and contractual requirements. This role evaluates behavioral health services for accuracy, appropriateness, and completeness. This is a non-direct care position requiring strong clinical expertise in behavioral health.
Key Responsibilities
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Conduct prospective, concurrent, and retrospective reviews of behavioral health services
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Evaluate medical records to determine medical necessity and adherence to established guidelines
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Ensure accuracy, quality, and timeliness of all reviews
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Manage daily workload and review queues to meet productivity standards
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Collaborate with internal teams on quality improvement initiatives
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Serve as a liaison for providers, addressing inquiries and resolving service-related issues
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Maintain current knowledge of behavioral health practices, policies, and review criteria
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Participate in team meetings and ongoing training
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Ensure compliance with HIPAA and all organizational policies
Required Qualifications
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Active, unrestricted Arkansas license in good standing in one of the following:
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LCSW, LMSW
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LAMFT, LMFT
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LAC, LPC
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LPE, LPE-I
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Master’s degree in Behavioral Health or a related field from an accredited institution
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Minimum of 2+ years of experience in a behavioral health setting, including utilization review or case management
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Strong knowledge of medical, psychiatric, and psychological terminology
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Experience reviewing mental health assessments and treatment plans
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Understanding of behavioral health services across inpatient and outpatient settings
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Ability to handle confidential HIPAA information with discretion
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Strong interpersonal, organizational, and communication skills
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Ability to collaborate effectively with providers and stakeholders
Preferred Qualifications
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Experience working with child and adolescent populations
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Experience in Utilization Review (UR) or Utilization Management (UM)
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Clinical quality review and medical record evaluation experience
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Familiarity with Arkansas Medicaid medical necessity criteria
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Knowledge of Arkansas Medicaid behavioral health policies and procedures
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Proficiency with automated review systems and Microsoft Office Suite
#AC