[Hiring] Clinical/Behavioral Health Specialist, Utilization Management @Community Health Options

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more.

Role Description

The Clinical Specialist reports to the Assistant Manager, Medical Management and provides clinical decision-making support and community resource coordination in support of Community Health Options Medical Management approach.
• Balances advocacy for the individual based on benefit design with stewardship for the entire individual and group membership through effective utilization management strategies.
• Supports Medical Management operational needs to ensure effective and efficient program coordination across the health continuum.
• Employs critical thinking skills to effectively manage complex medical and behavioral health presentations.
• Demonstrates ability to swiftly adapt and flex work assignments based on daily operational priorities.
• Responsible for performing medical necessity reviews for appropriateness of authorization of behavioral health care services (IP/OP/PHP/IOP etc.) and some medical services such as imaging and other outpatient medical services.
• Remote work is required; must provide sufficient internet bandwidth and have a home office environment that protects the privacy and integrity of confidential information.

Qualifications
• Completion of an accredited registered nursing (RN) or licensed practical nursing (LPN) degree program.
• Minimum of one (1) year of experience in Utilization Management/Utilization Review.
• Minimum of two (2) years of behavioral health clinical experience required.
• Current, unrestricted Maine Registered Nurse license (RN) or compact state RN license or Maine Licensed Practical Nurse (LPN) license or compact state LPN license required.
• Change resiliency.
• Experience with MCG Guidelines required.

Requirements
• Consistently exhibits behavior and communication skills that demonstrate Health Options commitment to superior customer service.
• Efficiently coordinates medical services to facilitate Members receiving the right care, at the right time, in the right setting.
• Using approved evidence-based clinical criteria, reviews requests to determine if submitted clinical documentation supports medical necessity.
• Consults with or refers case to Medical Director for complex clinical presentation or medical necessity review.
• Appropriately identifies and refers cases to claim operations queue (i.e., subrogation, coordination of benefits, clinical research).
• Collaborates with the Care Management Team and ensures appropriate referrals are placed.
• Establishes relationships with local providers, health care organizations discharge planners/coordinators, and community resources, as applicable.
• Completes accurate and timely documentation according to established policies and procedures.
• Participates in quality improvement activities and professional development such as Interrater Reliability (IRR).
• Consistently references approved resources and follows established department procedures and workflows.
• Maintains confidentiality in all aspects of Member and proprietary company information.
• Ability to effectively deescalate Member and provider emotionally charged situations.
• Ability to maintain production levels and quality standards with minimal direct supervision.
• Performs additional duties as assigned.

Company Description

Apply Now

Apply Now