Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria. Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network. Asassigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms. Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs and policies, procedures and criteria. Develops and manages new enrollee transitions and those involving a change in provider relationships. Develops and implements transition plans, as indicated, to ensure continuity of care. Negotiates and documents single case agreements according to procedures. In conjunction with providers and facilities, identifies, develops and monitors discharge plans. Collaborates with the Care Coordination team to implement support for transitions in care. Facilitates timely sharing of enrollees' clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care. Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases. Assures that case documentation for each decision is complete, including related correspondence. Participates in Care Coordination team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.
Maintains an active work load in accordance with performance standards. Works with community agencies as appropriate.
Participates in network development including identification and recruitment of quality providers as needed. Advocates for the enrollee to ensure health care needs are met. Interacts with providers in a professional, respectful manner.
Provides coverage of Nurse Line and/or Crisis Line as requested or required for position.
Qualifications:
Associates - Nursing Bachelors - Nursing Bachelors - Social Work Social Work Masters - Social Work LPN LCSW - Licensed Clinical Social Worker LMHP - Licensed Mental Health Professional LPC - Licensed Professional Counselor LMFT - Licensed Marital and Family Therapist LISAC - Licensed Independent Substance Abuse Counselor certification. RN or clinical credentials in a behavioral health field.
If nurse, RN license at a minimum. If not an RN, must hold Masters or Doctoral Degree.
If other than RN, Masters level licensed behavioral health professional. Good organization, time management and verbal and written communication skills. Knowledge of utilization management procedures, Medicaid benefits, community resources and providers. Knowledge and experience in diverse patient care settings including inpatient care. Ability to function independently and as a team member. Knowledge of ICD and DSM IV coding or most current edition. Ability to analyze specific utilization problems and creatively plan and implement solutions.
5-7 years' experience post degree in a clinical, psychiatric and/or substance abuse health care setting.
Minimum of 5 years of experience conducting utilization management according to medical necessity criteria required.