Quality Improvement/Utilization Management Generalist
Community Reach Center - Thornton, CO

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Community Reach Center, a top-tier mental health provider in the northern Denver area, and the designated mental health provider for anyone eligible for Medicaid in Adams County, Colorado.

We are seeking a Quality Improvement/Utilization Management Generalist. Under direct supervision of the Manager of Quality Improvement and Utilization Management, the Quality Improvement/Utilization Management Generalist is responsible for professional support for quality improvement and utilization management functions.

Duties and Responsibilities:

· Responsible for the implementation of UM monitoring/reporting, including timely authorization completion, modification reporting, etc.

· Understanding of medical necessity/level of care criteria for both internal and external providers/services/payor sources.

· Responsible for providing liaison functions with hospitals and external treatment facilities to assist CRC and Adams County consumers appropriately discharge to treatment.

· Assists Manager in coordination of Peer Review sessions.

· Assists Manager in data analysis, report development, communication and training based on results of utilization management/quality improvement projects to ensure full completion of the continuous quality improvement process.

· Performs Contracted Provider Network (CPN) functions to include the utilization management of CPN services.

· Assists Manager in Critical Incident tracking and monitoring, follow up, and reporting to regulatory agencies.

· Assists Manager with determining corrective actions/trainings with employees and teams that are targeted through Critical Incident monitoring.

· Assists in conducting case and clinical record review per developed medical necessity criteria and procedures to determine eligibility for services, program assignment, and length of stay.

· Assists in monitoring compliance with regulatory, accrediting body and internal standards related to quality improvement and utilization management.

· Acts as a resource to staff to provide information and support for effective quality improvement/utilization management processes and procedures.

· Understands and can assist with the releasing of health information guidelines and the processing of requests for records.

Other Functions

· Serves as a representative/role model of Community Reach Center with program consultants, consumers, families and the community as required. Projects a positive image to other agencies and general public.

· Participates in and utilizes opportunities that provide professional growth through attendance at center in-services and other conferences and by conducting consultation and education functions as indicated.

· Promotes cooperative working relationships and positive team atmosphere.

· Perform other such duties as assigned within the scope of the position and program description, as well as those reflective of experience, education and ability.

Work experience requirements:

Any combination of education and experience that would provide the required skill and knowledge for successful performance would be qualifying. Typical qualification would be equivalent to:

  • Minimum of a Master’s degree in Psychology, Social Work, Sociology or directly related field.
· Clinical and administrative experience.

· Excellent understanding of clinical service delivery and regulatory compliance.

Required Competencies:

· Problem Solving: Effectively analyzes potential for risk and acts decisively. Exercises good judgment by making sound and well-informed decisions. Must possess the ability to set priorities and avoid crisis management.
  • Critical Thinking: Demonstrates the ability to formulate a workable solution to a complex problem, through deliberating about what course of action to take, or analyzing the assumptions and the quality of the methods used in scientifically arriving at a reasonable level of confidence about a given hypothesis. Ability to employ logic, clarity, credibility, accuracy, precision, relevance, depth, breadth, significance and fairness.
· Data Analysis: Secures relevant information and identifies key issues and relationships from a base of information. Relates and compares data from different sources. Identifies cause-effect relationships.

· Organizational Awareness: Understands and uses the organization's structure, operations, decision making channels, planning processes, and financial budgeting/control systems to identify potential organizations problems and opportunities.

· Project Management: Ability to plan and organize resources in order to move a specific task, event or duty toward completion. Define the goals and objectives of the project, determines when the various project components are to be completed and by whom, and create quality control checks to ensure that completed components meet a certain standard. Demonstrated ability to manage multiple priorities/projects.

· Computer Competence: D emonstrated ability to perform basic mastery of Microsoft Outlook, Word, Excel, Access and Visio as well as Electronic Health Record systems utilized by Community Reach Center.

Required Licenses/Certifications:

· LCSW, LPC, LMFT, Licensed Psychologist

Desirable Qualifications:

· Bilingual English/Spanish

Community Reach Center is an Equal Opportunity Employer.

Community Reach Center - 23 months ago - save job
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