At APS Healthcare, we are passionate about changing behaviors of all constituents in the healthcare system to improve health, optimize clinical quality, and reduce associated costs. Our mission, quite simply, is to improve the health of those we serve.
APS has an exciting opportunity for a RN Clinical Care Manager in our Charleston, WV office. The Care Manager’s primary responsibilities include integration of clinical information related to prior authorization requests within established time frames for Medicaid outpatient behavioral health services and case discussions with providers regarding clinical recommendations/service utilization. This position will assist team members with updating utilization criteria, the development of internal review protocols and establishing individual recommendations for provider technical assistance and training related to best practices. The Clinical Care Manager will provide customer service, consultation to providers and contractors, and will have knowledge of behavioral health conditions, best practices and ability to integrate information for medical necessity determination.
• Review prior authorization clinical requests and subsequent documentation to establish medical necessity by integrating utilization management and interpretive guidelines within established time frames. Provide exceptional customer service, consultation to both providers and APS contractors in accordance to meet program deliverables.
• Identify service utilization trends, potential provider issues, assist in maintaining current clinical resources, consult with appropriate staff regarding medical necessity determination and continuing stay criteria for challenging cases.
• Actively participate in training providers and internal staff related to issues based upon prior authorization requests and utilization data.
• Maintain inter-rater reliability with clinical team members; participate in review activities with auditors as required; basic familiarity with entire APS-WV’s Scope of Work.
• Perform cross-training functions as needed related to other APS-WV programs.
• Other clinical duties as assigned.
• Associate’s degree in Nursing required. BSN preferred.
• Must have an unrestricted and valid RN license in the state of West Virginia.
• Minimum of 3 years experience in outpatient or inpatient behavioral health setting; one of the years have been providing direct service.
• Medicaid/Public Sector service experience strongly preferred.
• Utilization management experience a plus.
• Possess clinical knowledge of behavioral health conditions affecting population groups.
• Familiarity with computer applications and navigation through multiple screens.
• Familiarity with APS-WV programs.
• Maintain confidentiality standards and HIPAA compliance when evaluating all pertinent issues.
• Able to organize and prioritize tasks to meet timeline.
• Good interpersonal communication, telephone and negotiation skills.
• Ability to identify and fulfill provider training needs.
• Ability to work within a team yet maintains an individual caseload.
• Ability to utilize Microsoft software and web applications.
• Ability to integrate clinical knowledge, best practices and research to formulate decisions regarding medical necessity and service appropriateness.
• Able to updating review protocols, utilization management guidelines and other resource documents according to updated clinical information/literature.
• Ability to integrate information related to other APS –WV programs and performs applicable functions when necessary.