29 days old

Utilization Coordinator - Behavioral Health

Umpqua Health
Myrtle Point, OR 97458
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  • Job Code
    147129916
Full Time - Regular
Remote, Roseburg, OR, US



POSITION PURPOSE

The Utilization Review Coordinator - Behavioral Health is a member of the Utilization Management team for Umpqua Health Alliance (UHA). This position is responsible for timely completion of authorization requests and review utilization of mental health and substance abuse services provided in inpatient, outpatient, residential and intermediate care settings.



ESSENTIAL JOB RESPONSIBILITIES
  • Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
  • Performs prior authorization, concurrent reviews, and monitoring activities for mental health and substance abuse problems
  • Verify member eligibility and existing benefits for mental health and substance treatment, prior to authorizing all levels of treatment including concurrent outpatient.
  • Apply medical health benefit policy and medical management guidelines to authorize services.
  • Determines medical necessity and appropriateness of services using evidence-based clinical criteria sets (i.e. InterQual, MCG) to review documentation submitted by providers.
  • Requests additional information and/or request clarification if needed to make a determination.
  • Utilizes behavioral health knowledge and skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations.
  • Uses clinical knowledge and independent critical thinking skills to apply the appropriate criteria to make a medical necessity determination.
  • Accurately documents all review determinations and contacts providers according to established timeframes.
  • Track authorization expiration timelines and advise appropriate parties of exhaustion of benefits.
  • Ensure compliance with all performance measures in regards to appeals, denials, higher level of care admission certification and concurrent review timeliness, readmissions, and others as indicated.
  • Assesses, identifies and coordinates discharge plans and potential cases to the Care Coordination department.
  • Identifies and refers cases that do not meet established clinical criteria to the Medical Director.
  • Interact with Medical Director or designee to discuss clinical authorization questions and concerns regarding specific cases.
  • Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost-effective care delivery.
  • Responsible to ensure that treatment delivered is appropriately utilized and meets the member's needs in the least restrictive, least intrusive manner possible.
  • Work with the behavioral health care coordinators to ensure member receive integrated care coordination as needed.
  • Direct and coordinate follow-up to ensure plans for continuity of care.
  • Communicates information to other staff members as necessary/required.
  • Collaborates with Claims, Clinical Engagement, Third-Party Recovery (TPR) and Provider Relations departments as requested.
  • Establishes and maintains relationships with community services and providers.
  • Participate in quality improvement activities, supporting network development and interfacing with treatment facilities and the professional community.
  • Identifies and refers quality issues to the Utilization Management Director.
  • Performs accurate data entry in order to meet quality goals.
  • Participates in continuing education initiatives.
  • Maintains updated knowledge and understanding of the laws, regulations and policies, including, but not limited to, the OARs, CFRs, ORSs that govern the Oregon Health Plan as well as all applicable Medicare guidelines. It also includes the policies and procedures that apply to the appeal and grievance process, prior authorizations, covered services and the members rights and responsibilities as stated by the Division of Medical Assistance Program (DMAP) as well as CMS.
  • Work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
  • Assures patient confidentiality, privacy, and health records security.
  • Other duties as assigned.



GUIDING BEHAVIORS

Accountability

Always demonstrate the highest performance and behavior standards. Share responsibility and expect others to be accountable.

Efficiency

Demonstrate a proactive approach to problem identification and solutions. Be innovative and solutions oriented, improving processes while reducing costs. Demonstrate appropriate time-management skills. Optimize the use of available resources.

Be a Team Player

Support and assist your team members. Be available to help, and learn from your team. Keep an open mind to feedback and earn trust of staff.

Integrity

Keep your promises, commitments, and confidences. Be honest and straightforward dealing with all issues fairly and consistently.

Stewardship

Adhere to all state and federal regulations relating to your position including the Health Insurance Portability and Accountability Act (HIPAA), Fraud & Abuse and Occupational Safety and Health Administration (OSHA) laws. Abide by Company policies and procedures at all times.



CHALLENGES
  • Working with a variety of personalities, maintaining a consistent and fair communication style.
  • Satisfying the needs of a fast paced and challenging company.



QUALIFICATIONS
  • REQUIRED - Bachelors degree
  • REQUIRED - Masters degree in behavioral health field of study plus two (2) years post-graduate experience in behavioral health
  • REQUIRED - Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), Licensed Clinical Social Worker (LCSW), Licensed Psychologist, or RN with (3) years of behavioral health experience
  • REQUIRED - CADC I and higher
  • PREFERRED - Experience in utilization management, case management and managed care
  • Knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits.
  • Ability to understand contractual benefits and options available outside contractual benefits.
  • Working knowledge of community services, providers, vendors and facilities available to assist members.
  • Understanding of appropriate care plans.
  • Ability to work independently with minimal supervision.
  • Ability to use computerized systems for data recording and retrieval.
  • Proficiency with Microsoft Office products.
  • Remote or Work from home: Must have a separate room with a locked door that can be used as a home office to ensure you and your patients have absolute and continuous privacy while you work.
  • Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required.



PHYSICAL DEMANDS

Typical office environment requiring standing, sitting, walking, bending, and lifting up to 25 pounds. May be exposed to member and environment conditions such as unpleasant sights, smells and contagious diseases.






PI147129916

Posted: 2021-09-16 Expires: 2021-10-17

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Utilization Coordinator - Behavioral Health

Umpqua Health
Myrtle Point, OR 97458

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