Utilization Management Behavioral Health Professional Jobs

Manages clients in crisis utilizing appropriate therapeutic skills and assessment techniques.

Designs, plans, implements effective patient education.

Develops, implements and evaluates patient care according to identified needs.

Collaborates with appropriate guardians and community agencies to insure effective service delivery.

Maintains open lines of communication, collaborates with healthcare team for patient outcome.

This position is Sign-on Bonus eligible for a bonus of $3,000 for Full Time positions.

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.

At least years of experience in negotiating managed care contracts with physician, hospital and/or other provider contracts

Experience with behavioral health contracting

Excellent written and verbal communication skills

Ability to manage multiple priorities in a fast-paced environment

Experience working with Medicaid contracts

This is a remote position; however, candidates must reside in the state of Indiana.

Computer skills in word processing, database management, and spreadsheet desirable.

Knowledge in areas of: Medicare and Medicaid UM regulations, McKesson InterQual, and Denial Management.

Two (2) years of experience in Acute Clinical Care or Medical Management setting, adult and children.

Identifies members that are high risk or have conditions that may need case or disease management.

Enters and maintains pertinent clinical information in health management system.

Participates in utilization management committees and works on special projects related to utilization management as needed.

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

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

Provide direct oversight to a utilization management team, for employees at multiple locations across the country (remote)

3+ years of people management experience (managing direct reports, coaching, training, performance reviews, running team meetings, etc.)

Proven excellent communication, collaboration, team building and relationship management skills

Provides leadership to and is accountable for the performance of managers and/or senior level professional staff

5+ years of experience managing a clinical/operational unit in a broad range of settings

Experience interfacing with providers and solutioning gaps

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

Above average PC skills, ability to work, ability to multi task using multiple systems during call processing

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Pleasefind below the detailed job description:

Term: 9+ months (Contract with possible extension)

Shift: Tuesday 6am-4pm, Thursday, Friday, and Saturday 10am-8pm

Describe the performance expectations/metrics for this individual and their team:

Proficient to advanced knowledge in Behavioral Health HEDIS interventions, member experience, member safety, and innovation implementation strongly preferred.

Extensive experience in behavioral health strongly preferred.

Experience leading a quality improvement team within an NCQA MBHO framework strongly preferred.

Extensive experience working in a highly matrixed environment strongly preferred.

National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint

Produces QM documents, including tracking and updating Work Plan activity progress.

Proficient to advanced knowledge in Behavioral Health HEDIS interventions, member experience, member safety, and innovation implementation strongly preferred.

Extensive experience in behavioral health strongly preferred.

Experience leading a quality improvement team within an NCQA MBHO framework strongly preferred.

Extensive experience working in a highly matrixed environment strongly preferred.

National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint

Produces QM documents, including tracking and updating Work Plan activity progress.

Proficient to advanced knowledge in Behavioral Health HEDIS interventions, member experience, member safety, and innovation implementation strongly preferred.

Extensive experience in behavioral health strongly preferred.

Experience leading a quality improvement team within an NCQA MBHO framework strongly preferred.

Extensive experience working in a highly matrixed environment strongly preferred.

National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint

Produces QM documents, including tracking and updating Work Plan activity progress.

Proficient to advanced knowledge in Behavioral Health HEDIS interventions, member experience, member safety, and innovation implementation strongly preferred.

Extensive experience in behavioral health strongly preferred.

Experience leading a quality improvement team within an NCQA MBHO framework strongly preferred.

Extensive experience working in a highly matrixed environment strongly preferred.

National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint

Produces QM documents, including tracking and updating Work Plan activity progress.

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.