Utilization Management Specialist (LCPC/LCSW-C)

Location: Telecommute

Company

hirify.global provides contract staffing opportunities for technical and specialized professional roles.

What you will do

• Perform prospective, concurrent, and retrospective utilization reviews for authorization, appropriateness of care, and benefit coverage.
• Determine medical necessity and appropriate clinical services using contracts, regulatory mandates, medical policies, and accepted clinical guidelines.
• Research diseases, treatments, emerging technologies, and high-cost services to support recommendations to medical directors.
• Collaborate with medical directors, contracting, provider services, member services, sales, and marketing teams on benefit application and care decisions.
• Coordinate non-participating provider and facility case-rate negotiations.
• Refer members and providers to alternative care settings and present educational topics to internal audiences.

Requirements

• One or both licenses required: LCPC or LCSW-C with an active license in Maryland, Washington, DC, or Virginia.
• Master's degree in Psychology or Social Work.
• At least five years of clinical experience.
• Experience treating both substance use and mental health conditions.
• Working knowledge of managed care and behavioral health delivery systems.
• Strong Microsoft Excel skills and experience with GuidingCare or a similar utilization management platform; Milliman Care Guidelines and Apollo Guidelines required.

Nice to have

• Two years of care management experience.

Culture & Benefits

• Telecommute work arrangement.
• Contract engagement lasting 6–12 months.
• Work involving collaboration across clinical, provider, member, contracting, and medical leadership functions.