Behavioral Health Utilization Review Coordinator Jobs

2 years Mental Health experience preferred.

The Therapist responsibilities include, but are not limited to, the following:

Provides documentation daily in the chart of each patient.

Facilitates discharge planning to assist patients in placement and treatment following discharge from current level of care.

Participates in the writing of treatment plans and attends treatment team meetings.

Facilitate the completion of Emergency Detention paperwork as well as ensure its distribution and receipt by legally designated individuals.

Invites you to apply for:

BEHAVIORAL HEALTH UTILIZATION REVIEW SPECIALIST

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Two or more years of behavioral health experience.

Strong problem solving skills and decision making skills.

This position requires residency in the state of North Carolina.

Current active professional licensure required in North Carolina: LCMHC, LCSW, RN

Proficiency in Microsoft Office, including Word, Excel and Outlook is required.

Ability to communicate in a positive/professional manner both orally and written.

Starts at $30-31+ per hour based on experience, education, and certifications.

Possess one of the following certifications: (RN, DC, PT, DPT, LVN, OT, LAc).

1 year of clinical experience

Knowledgeable with computer programs (MS Word, MS Excel, Email) and toggling between multiple screens.

Medical, Dental & Vision Insurance

Paid Time Off & Paid Holidays

3+ years of utilization management experience

Provide management of behavioral health services, including crisis assessment and intervention

Administer benefits, review treatment plans, and coordinate transitions between various areas of care

Undergraduate degree or equivalent experience

1+ years of experience with MS Office, including Word, Excel, and Outlook

Experience in serving individuals with co-occurring disorders (both mental health and substance use disorders)

Provides educational services to the Utilization Management staff

Requires knowledge of managed care contracting, Medical Necessity, CMHRS services, DMAS protocols, clinical protocols and clinical review requirements

Minimum 1 year experience in Managed Care Setting (MCO)

First line supervisor in the Utilization Management Department

Provides a leadership role in ongoing utilization review competency assessment, needs identification and educational offerings

Requires knowledge of contractual, regulatory and compliance requirements for government payers, self funded and commercial payers

Demonstrated knowledge of payers, payer systems, cost effective utilization management and InterQual criteria.

One year Utilization Review or Case Management experience.

Knowledge / Skills / Abilities

Upload most recent updated resume with work history and experience, please include Month and Year in formatting.

Alerts and discusses with physician/provider and case manager/discharge planner when patient no longer meets medical necessity criteria for the inpatient stay.

Demonstrated team leadership, relationship building, critical analysis, and written and verbal communication skills.

Excellent data entry skills and ability to navigate electronic systems applicable to job functions

Ensure all pre-certifications are completed for inpatient and outpatient services

Work with facilities to ensure documentation requirements are met

Interface with managed care organizations, external reviews, and other payers

2 or more years experience billing UR healthcare industry – in the mental health/addiction field.

Working knowledge of clinical case formulation for substance abuse/mental health treatment.

Appropriate and complete documentation of clinical review and denial management in the case management documentation system and in the billing system.

Position Qualifications Required / Experience Required:

Manages the concurrent denial process by referring to appropriate resource for concurrent and retrospective appeal activity process.

Understands and applies applicable federal and state requirement.

Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.

Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues.

5-8 years post-master’s direct clinical experience, including utilization management in behavioral health or managed care

Provide monthly Care Management report on team(s) performance, metrics, and goal achievement to the Director of Behavioral Health.

Demonstrated understanding and proficiency in the principles, concepts and techniques of managed care and utilization management.

Able to manage ambiguity and change, and lead a team’s effective management of shifting priorities, competing demands, and rapidly changing conditions.

5-8 years of supervisory experience preferred

Experience with Medicare and Medicaid

Coordinate utilization management reviews for all assigned inpatient, partial hospitalization and intensive outpatient program patients.

Coordinates closely with Director of Utilization Management, Nursing and Clinical Services.

Follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with external review agencies.

Obtains authorizations for services, coordinates peer-to-peer reviews for assigned caseload.

Understands medical necessity criteria and facilitates accurate and timely documentation to support advocacy of services.

Master’s Degree in Social Work, Marriage and Family Therapy or Counseling from an accredited school or BSN, RN

Knowledge, Skills and Abilities (KSAs)

Two years’ experience in health care/managed care setting or previous work experience within division

·Knowledge of basic medical terminology and concepts used in managed care., Proficient

accommodations may be made to enable individuals with disabilities to perform the essential functions.

Knowledge of CPT and ICD-10 coding.

·Excellent communication, organizational and customer service skills. , Proficient

Five years (60 months) of RN experience.

Current AHA BLS/CPR and other required unit specific certifications

Effective communication skills (oral and written) that facilitate therapeutic relationships between patients, family, and health care providers

Intermediate computer skills with the ability to become proficient in the Electronic Health Record (EHR) with on-the-job training

Excellent attendance, interpersonal skills and work history required.

Facilitates coordination of patient services in assigned patient care unit, or department

Utilization management experience, preferably in an outpatient setting.

Coordinates with Care Coordination and Case Management.

Three (3) or more years of post-degree clinical experience in direct patient care.

Three (3) or more years of Behavioral Health experience.

Experience working in electronic medical records.

Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

Possesses skill set to provide clerical support to the Case Management Department.

Excellent time management skills with a proven ability to meet deadlines.

Demonstrates knowledge and skill set to process BHU Medical TARS

Regularly attends required in-services and continuously takes an active interest in furthering one's knowledge.

Has the willingness and ability to perform all other duties and responsibilities as assigned

Five years + experience in acute care hospital Utilization Review and RN Required

Identify high cost utilization and refer to Large Case Reinsurance RN and Care Management team as appropriate.

Coordinate necessary resources to achieve member outcome goals and objectives.

Accurately document case notes and letters of explanation which may become part of legal records.

Perform concurrent review of members admitted to inpatient facilities, residential treatment centers, and partial hospitalization programs.

Maintain contact with the inpatient facility utilization review personnel to assure appropriateness of continued stay and level of care.

Review referral and preauthorization requests for appropriateness of care within established evidence-based criteria sets.

1-3 years clinical experience in a hospital, acute care, home health/hospice, direct care or case management required.

1-3 years experience in care coordination or case management required.

Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment.

Prefer experience in health plan case management, care coordination, or member navigation.

Home care/field based case management experience.

Support and collaborate with the UM and CM Managers and Supervisors in the implementation and management of UM/CM activities

Maintains issue tracker related to third party denials and interfaces with management as needed to initiate investigation of denials.

Oversees and supports staff with wound care and patient education.

Attends unit leadership meetings. Collaborates regarding unit issues and quality assurance. Provides staff education as appropriate.

Working knowledge of psychiatric diagnostics required

Third party reimbursement knowledge desirable

Willingness to work toward CPUR certification preferred

Possesses and can demonstrate the professional and technical skills required

Experience in UR, Workers' Compensation experience highly preferred, but not required

Excellent Written and Oral Communication Skills

Responsibilities may include, but are not limited to:

Perform a complete evaluation of the medical data for the request

Collect additional relevant data as needed to decide on medical necessity