Healthcare Consultant III

Job Description

Duties & Responsibilities:

• Review clinical information and apply medical necessity criteria, clinical guidelines, policies, and professional judgment to render coverage determinations and discharge planning decisions.
• 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.

Required 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.

Required Education:

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