Clinical Care Reviewer UM
Responsible for understanding the Behavioral Service Delivery System and access to that system. Work closely with Member, Member’s family, and providers to determine appropriate level of care to meet treatment needs. Care Managers are responsible to ensure that treatment delivered is appropriately utilized and meets the Member’s needs in the least restrictive, least intrusive manner possible.
- Conducts clinical screening, make appropriate determinations regarding level of care based on medical necessity criteria, and complete authorizations within established timeframes.
- Review information and document findings from Members, families, providers, and other involved persons to determine an appropriate level of care.
- Complete case management follow-up activities and integrated care coordination with medical case managers.
- Direct Member care through the authorization of services and discharge planning.
- Reports utilization trends, clinical issues and operational concerns regarding Level of Care (LOC) within Behavioral Service Delivery System to Care Management Supervisor. Considers all information available to ensure that authorizations are not provided for unbundled, excessive, or duplicative services. Report any atypical or inappropriate authorization requests and any treatment concerns to Care Management Supervisor.
- Care Managers are responsible for submitting all LOC requests that may not meet MNC to a CBHNP Physician Advisor ( PA), or Psychologist Advisor when appropriate, for review and final determination of approval or denial of care. A Care Manager is not permitted to deny a request for services, only a CBHNP PA may issue a denial of care.
- Implement and adhere to all CBHNP policies and procedures including but not limited to: the Employee Handbook, Corporate Code of Conduct, Confidentiality, and Corporate Compliance.”
- Adhere to all documentation requirements as outlined in for CBHNP Agency and Clinical policies, procedures, and internal processes.
- Participate in other projects as assigned.
- On-Call responsibilities during non-business hours as scheduled.
- Maintain caseload as assigned.
- Other duties as assigned.
- Graduate degree from an accredited educational program in Social Work, Clinical/Counseling Psychology, or Nursing.
- Must hold a valid, unrestricted state license in a behavioral health specialty or nursing.
- Minimum of three years post-graduate clinical experience or equivalent combination of education and clinically related work experience
- Minimum of one-year experience working with a managed care system.
- Minimum of one-year experience in Behavioral Health Service Delivery System.
- Previous Supervision or proven leadership experience required.
- Knowledge base in medical management , preferably Medicaid Managed Care Systems
- Strong written and oral communication skills
- Ability to perform multiple tasks
- Excellent interpersonal personnel and organizational skills
- Ability to work effectively in a team environment
- PC skills and experience utilizing Microsoft Office, Outlook, Excel, Power Point
AmeriHealth Caritas - 17 months ago