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BH
Behavioral Health Co.
Experienced QP
Career Insights for Clinical Auditor / Utilization Reviewer
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Scorecard
Based on North Carolina data
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What they do
A Clinical Auditor or Utilization Reviewer reviews the efficiency of healthcare delivery. Individuals tend to have had experience as a registered nurse or other healthcare delivery roles before transferring into this quality review role.
$98,851 / year median in North Carolina
-7% projected decline
Job Description
This position is best suited for an experienced Qualified Professional seeking supplemental income, a flexible PRN opportunity, or an additional part-time role. Applicants should be comfortable working independently and managing assigned responsibilities with minimal supervision. Position Overview Seeking an experienced, highly organized, and self-motivated Qualified Professional (QP) with extensive knowledge of North Carolina Medicaid behavioral health services, including 1915(i) services and the NC Innovations Waiver. This PRN position is ideal for an experienced professional seeking flexible supplemental work while serving in both a Qualified Professional and supervisory capacity. The successful candidate will independently complete initial Person-Centered Plans (PCPs), conduct required 90-day and annual PCP reviews, provide Qualified Professional oversight to paraprofessional staff providing community-based behavioral health services, and ensure all documentation complies with North Carolina Medicaid, LME/MCO, and agency standards. This position averages approximately 5-10 hours per week , with hours varying based on referrals and agency needs. Essential Duties and Responsibilities Person-Centered Planning Independently complete initial Person-Centered Plans (PCPs). Conduct timely 90-day PCP reviews and annual PCP updates. Review all required life domains and ensure plans accurately reflect the member's current strengths, needs, preferences, and progress. Develop and revise long-term goals, short-term SMART goals, interventions, and crisis plans. Ensure documentation supports ongoing medical necessity. Coordinate Person-Centered Planning meetings with members, legally responsible persons (when applicable), Care Managers, providers, natural supports, and other interdisciplinary team members. Monitor PCP due dates to ensure all reviews are completed within required Medicaid timeframes. Qualified Professional Oversight Provide Qualified Professional supervision and oversight to paraprofessional staff providing community-based behavioral health services. Conduct required supervision in accordance with North Carolina Medicaid requirements and agency policy. Maintain regular monthly communication with assigned paraprofessional staff to review member progress, service implementation, documentation, barriers to treatment, and professional development needs. Maintain regular monthly communication with members receiving services to monitor satisfaction, progress toward goals, service effectiveness, and any identified concerns or changes in needs. Review service documentation to ensure compliance with Person-Centered Plans, Medicaid documentation standards, and agency policies. Provide coaching, guidance, and corrective feedback to paraprofessional staff regarding documentation, person-centered practices, professional boundaries, service implementation, and Medicaid compliance. Monitor implementation of Person-Centered Plans and verify that services are being delivered as authorized. Identify documentation deficiencies and work collaboratively with staff to ensure timely corrections. Assist with quality assurance activities, documentation reviews, and audit preparation. Collaboration Collaborate with Care Managers, therapists, peer support providers, healthcare providers, guardians, families, and other members of the interdisciplinary treatment team. Participate in treatment team meetings as needed. Communicate professionally with internal and external stakeholders regarding member progress and service needs. Report concerns, barriers, and recommendations to agency leadership in a timely manner.