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Specialist, Utilization Management-Mental Health

Company

Kaiser Permanente
Address , Portland, Or
Employment type
Salary $42.50 - $54.94 an hour
Expires 2023-07-20
Posted at 1 year ago
Job Description
Ensure consistent application and management of Kaiser Permanente mental health and chemical dependency benefits.
Essential Functions:
  • Benefit payment authorizations. Manage behavioral health benefits by providing medical necessity determinations. Medical necessity determinations are completed by gathering the most current clinical information from the assessing/treating provider and applying the approved Kaiser Permanente medical necessity criteria to determine what can be authorized within the benefit provisions. Medical necessity criteria are used for all pre-authorization, concurrent review and post-service requests. Authorizations must be for the most clinically appropriate, least restrictive, most cost effective and within standards of care to safely treat the member.

  • Member contact. Member contact may occur for a variety of reasons which can include benefit explanations, resource identification and appointment scheduling.

  • Payment denials. Kaiser policies are followed for all benefit payment denials. UM coordinator is always available to explain a payment denial to providers and members.

  • Consultations. Consultations are provided to internal and external providers regarding medical necessity interpretation, benefits, covered services, contracted providers and available resources that meet the clinical needs of the Kaiser member.

  • Fraud and abuse. Responsibility for ensuring the appropriate expenditure of healthcare dollars in accordance with rules and regulations set forth in Kaiser policies, licensing and credentialing entities and all state and federal laws and regulations.

  • Ensuring continuity of care by facilitating communication between service providers regarding treatment planning, intervention, outcomes, and recommendations.

  • Care coordination. Ensuring upon discharge from higher levels of care that all members have an appropriate discharge plan within HEIDIS guidelines.

  • On-call rotation as assigned to cover pre-authorizations for non-business hours.

Basic Qualifications:
Experience
  • Minimum three (3) years of experience working directly or indirectly with individuals with mental health or chemical dependency conditions, which would include diagnosing, treating or managing.

  • Minimum two (2) years of experience in utilization management and discharge planning.

Education
  • Master's degree in mental health, social work or closely related field from an accredited institution.

License, Certification, Registration
  • N/A

Additional Requirements:
  • Understanding of medical necessity criteria and its application.

  • Knowledge of DSM-IV diagnoses, community standards of treatment and treatment interventions for mental health, addictions and co-occurring disorders.

  • Familiarity with community resources.

  • Knowledge of how behavioral health benefits work.

  • Good clinical judgment in assessing the clinical needs of patients and matching those needs to the appropriate level of care.

  • Demonstrated ability to develop successful interpersonal relationships and earn the respect of physicians, nurses, therapists and other personnel.

  • Able to participate as a team member, but demonstrates high level of self-motivation and ability to work independently.

  • Excellent oral and written communication skills.

  • Excellent problem solving abilities, detail oriented, and very organized.

  • Use medical criteria for UM decision-making and education with patients, providers, and community providers.

  • Ability to effectively utilize computerized medical records.

  • Ability to use Microsoft Office software.

  • Ability to use analytical software.

  • Ability to collect, analyze, and report statistically meaningful quality and utilization data.

  • Excellent written and verbal communication skills; presentation skills; analytical problem-solving skills; well developed project management skills; and competent quantitative skills.

Preferred Qualifications:
  • Minimum five (5) years of experience working directly or indirectly with individuals with mental health or chemical dependency conditions, which would include diagnosing, treating or managing.

  • Current, unrestricted license/certificate in state where job is assigned:

  • Oregon Licensed Clinical Social Worker (LCSW) or Licensed Marriage and Family Therapist (LMFT) or Licensed Professional Counselor (LPC) or Licensed Psychologist (PhD or PsyD) or Certified Alcohol and Drug Counselor (CADC).

  • Washington Licensed Independent Clinical Social Worker (LICSW) or Licensed Advanced Social Worker (LASW) or Licensed Marriage and Family Therapist (LMFT) or Licensed Mental Health Counselor (LMHC) or Licensed Psychologist (PhD or PsyD) or Chemical Dependency Professional (CDP).

  • Understanding of Milliman Criteria, ASAM Criteria, and both Kaiser and community UM processes and procedures.

  • Knowledge of Kaiser Permanente resources, Behavioral Health system and benefits.

  • Understanding of insurance operations and applying benefits.

  • Ability to apply medical necessity criteria solely on clinical relevance and not basing decisions on financial outcomes.

  • Demonstrated ability to work with providers within contractual relationships and develop positive working relationships.

  • Ability to issue and explain adverse benefit determinations.

PrimaryLocation : Oregon,Portland,East Interstate Medical Offices
HoursPerWeek : 1
Shift : Day
Workdays : Mon, Tue, Wed, Thu, Fri
WorkingHoursStart : 08:30 AM
WorkingHoursEnd : 05:00 PM
Job Schedule : Call-in/On-Call
Job Type : Standard
Employee Status : Regular
Employee Group/Union Affiliation : NUE-NW-01|NUE|Non Union Employee
Job Level : Individual Contributor
Job Category : QA, UR & Case Management
Department : Interstate - East Medical Ofcs - Mental Health/Resource-Admin - 1008
Travel : Yes, 5 % of the Time
Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.