General Summary: Evaluates the clinical appropriateness of treatment using professional knowledge of ValueOptions Clinical Policy and Procedures and Benefit Plan requirements. Seeks case consultations for cases according to policy guidelines. Maintains confidentiality, promotes coordination of care and meets Care Manager I Career Ladder requirements.
Essential Duties and Responsibilities:
Conducts reviews for medical necessity of psychiatric/substance abuse cases utilizing professional knowledge while applying ValueOptions criteria consistently and render certification decisions that are within the scope of practice that is relevant to the clinical areas under review.
Utilizes rounds and case consultations with Clinical Supervisor/Manager/Director and Medical Director/Peer Advisor for cases outside criteria or not progressing.
Refers cases to Peer Advisors that do not meet criteria for decision of medical necessity.
Coordinates with providers and other Care Managers to assure that patient comprehensive treatment needs are met and that there is continuity of patient care.
Maintains confidentiality, ethical and professional standards, adhering to ValueOptions Clinical Policy and Procedures and Benefit Plan requirements.
Maintains departmental productivity and performance standards.
Meets standards set for Care Manager I in the Texas Commercial Service Center UM Career Ladder.
Other duties as assigned.
Education: Masters Degree in the mental health professions
Licensures: Current, valid and unrestricted license in a State or territory of the United States in a mental health field: Licensed Psychologist, LMSW, LCSW, LPC, LMFT, RN.
Relevant Work Experience: Three to five years experience in psychiatric and/or substance abuse treatment. Experience in settings that include inpatient, partial, and/or outpatient treatment and care management services in a behavioral care management organization preferred.
Supervise Staff? YES X NO
Value Options - 14 months ago
- 15 days ago
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