Performs utilization review of mental health and substance abuse services for inpatient, outpatient and intermediate levels of behavioral health care, using BHS Medical Necessity Criteria and approved processes that are in accordance with all regulatory standards and compliance with BHS policies and procedures.
1. Provides utilization review for preauthorization, concurrent and discharge reviews and post service review using BHS Medical Necessity Criteria to determine authorization for the requested level of care, or referral to BHS physician review.
2. Reviews and monitors utilization for members and plans and implements solutions that directly influence quality of care and financial liability- based on the needs of the member.
4. Collaborates with BHS Physician Advisors to discuss clinical authorization and quality of care.
5. Interacts with providers and facilities in a professional, respectful manner to coordinate treatment and discharge planning.
6. Complies with all BHS standards for documentation.
7. Demonstrates thorough understanding of product lines and benefit structure.
8. Provides information to members and providers regarding mental health and substance abuse benefits, and community treatment resources.
9. Identifies and refers high risk members for Case Management.
10. Recognizes quality of care issues and reports them appropriately through internal and external processes.
11. Assists with NCQA, URAC and other QI initiatives as needed
12. Other duties as assigned
SCOPE: Non-certifications may not be issued on initial review, and always require consultation with a Physician or Psychologist Advisor
Utilization Review clinicians are required to be educated in current principles, procedures and knowledge domains of utilization review based on nationally recognized standards of care management and must be a licensed behavioral health clinician. Utilization review Re-verification to occur at a minimum of every 3 years.
A staff providing utilization review services will have at least one of the following:
· Master’s degree or higher in a health related field and licensure as a behavioral health professional.
· BSN, licensure as a professional and 3 years behavioral health clinical practice
· Licensed behavioral health clinician/nurse who has Certification as a Case Manager is preferred.
Non-certifications may not be issued on initial review, and always require consultation with a Physician or Psychologist Advisor
COMPREHENSIVE CARE SINCE 1996
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