Conducts eligibility assessments and utilization reviews of behavioral health plus program (BHPP) services, assigns acuity level for care/case management services, and coordinates all behavioral health care and case management services to AlohaCare members who meet the criteria of Department of Human Services for adults with serious mental illnesses and children and youth who meet the criteria for Support for Emotional and Behavioral Development (SEBD) program. Duties and responsibilities are provided in compliance with State DHS-Med-QUEST requirements, state and federal laws, AlohaCare policies and procedures, and URAC standards.
Primary Duties and Responsibilities
Provider Relations/Care Management:
Assessment for Eligibility Process:
- Responsible for the day to day contacts with providers who are contracted by AlohaCare QUEST to provide care coordination and other designated services to these special populations.
- As requested or deemed necessary, provide clinical consultation to contracted agencies providing care coordination/case management to these populations
- Available to consult with care/case management providers in the development of Individual Care Plans (ICP) for each member and, for youth as needed, Individualized Educational Plans (IEP)
- Works to ensure collaboration of care coordination providers, behavioral health providers, and primary care physicians to maintain continuity in implementing each member’s Individualized care plan
- Collaborate with AlohaCare’s Provider Relations Department to train providers of these special populations in AlohaCare’s philosophy, policies and procedures as necessary.
- Collaborate with AlohaCare’s Quality Improvement Department in performing provider medical record reviews, measuring HEDIS outcomes, and identifying provider outliers
- Participates in the eligibility process by conducting assessment or referring member to contract provider for assessment documentation
- Attends Team meetings with BHPP MD Consultant for validation of eligibility.
- Assigns acuity level for care/case management services within designated time frames.
- Certifies care/case management services for each adult member.
- Receives and processes requests for precertification for all higher levels of Behavioral Health care included on the Individual Care Plan (ICP) for members, or Individualized Education Plan (IEP) for youth
- Receives and processes requests for precertification for all levels of Behavioral Health care that is not included on the member’s ICP or IEP. Consults with care coordination/case management providers, Family Guidance Center staff, the requesting Behavioral Health Provider’s (BHP), and the BHPP MD if necessary before processing the certification.
- Conducts concurrent utilization reviews of behavioral health inpatient stays and prepare related documentation. Participate in clinical review of all inpatient stays with BHPP Medical consultant. Collaborate with member’s assigned care/case manager and hospital staff on discharge planning.
- Follows AlohaCare policies related to recommending denials of any certification requests
- Documents UM activities (precertification, concurrent reviews) according to Aloha Care’s Policies and Procedures.
- Maintains an certification tracking system with clear, concise records for monitoring and reviewing cases per policy.
- Contributes to utilization management endeavors, policy review, and procedure development and evaluation.
Required Competencies and Qualifications:
- Documents member grievances and provider complaints in QNXT system.
- Facilitates inter-department activities and communication which promote and support natural work team efforts leading to successful integration of medical, behavior health, pharmacy, and care/case management services.
- Facilitates document preparation and maintenance which enables prompt response to claims submittal, regulatory agency audits and surveys and other internal and external requests for data.
- Participates in other Quality Improvement and Utilization Review activities as required.
- Completes monthly Inpatient Tracking for HEDIS requirements.
- Reports productivity tracking weekly.
- If applicable, maintains AlohaCare’s ACD Benchmarks on a consistent basis.
- Completes Inter-rater reliability testing quarterly and maintains a minimum score of 80%.
- AlohaCare employees are expected to maintain a positive work atmosphere through adhering to Aloha Care’s values
- Other duties as assigned.
- Behavioral Health Care Coordination and/or Case Management experience.
- Utilization management experience.
- Must be able to communicate clearly (verbally and in writing) internally and externally to facilitate action plans.
- Strong problem solving skills.
- Current valid State of Hawaii Drivers License
- Travel locally on a regular basis with occasional inter-island travel
- Provide external/external training sessions when necessary
Preferred Competencies and Qualifications:
- Bachelors Degree or higher in a health-related field with licensure as a health professional or
- RN/LPN licensure and three (3) years clinical practice experience
- Certification as a Case Manager through a URAC approved entity
- Managed Care experience
- 2-3 years work experience as a case manager in a community setting
- Proficiency in Microsoft Word and Outlook with basic understanding of and ability to enter data/run reports from Excel or Access databases.
- Knowledge of DSM IV and ASAM (PPC-2R)
- Knowledge of Interqual Criteria
- CSAC certification
An Equal Opportunity Employer
AlohaCare - 19 months ago