This position is available as a work from home position after 5 weeks of onsite training.
Under general supervision, and in collaboration with other members of the clinical team, authorizes and reviews utilization of mental health and substance abuse services provided in inpatient and intermediate care settings. Collects and analyzes utilization data. Assists with discharge planning and ambulatory follow up activity. Provides member assistance with mental health and substance abuse issues, and participates in special quality improvement projects.
ESSENTIAL FUNCTIONS: Monitors inpatient and intermediate level of care services related to mental health and substance abuse treatment to ensure medical necessity and effectiveness. Provides telephone triage, crisis intervention and emergency authorizations as assigned. In conjunction with providers and facilities, develops discharge plans and oversee their implementation. Performs concurrent reviews for inpatient care and other levels of care as allowed by scope of practice and experience. Provides information to members and providers regarding mental health and substance abuse benefits, community treatment resources, mental health managed care programs, and company policies and procedures, and criteria. Interacts with Physician Advisors to discuss Clinical/authorization questions and concerns regarding specific cases. Participates in quality improvement activities, including data collection, tracking, and analysis. Maintains an active work load in accordance with National Care Manager performance standards. Works with community agencies as appropriate. Proposes alternative plans of treatment when requests for services do not meet medical necessity criteria. Participates in network development including identification and recruitment of quality providers as needed. Advocates for the patient to ensure treatment needs are met. Interacts with providers in a professional, respectful manner that facilitates the treatment process.
Education: Masters Degree/Nursing Diploma
Field(s) of study: RN, Masters, or Doctoral Degree in behavioral health related field
Industry: Managed Care
Job Specific: 3 years experience post degree in psychiatric and/ or substance abuse health care setting, including utilization review. Associate Care Manager must have performance ratings of "meets expectations" or "exceeds expectations" in order to qualify for this position.
Knowledge, Skills, Abilities:
Other: Good organization, time management and communication skills; knowledge of utilization management procedures, mental health and substance abuse community resources and providers; knowledge and experience in inpatient setting; ability to function independently and as a team member; knowledge of DSM V or most current diagnostic edition. Ability to analyze specific utilization problems, plan and implement solutions that directly influence quality of care.
Computer Skills: Ability to use computer systems
Licenses, Certifications, etc.: RN license at. a minimum. Meets Magellan credentialing requirements for independent professional practice (Masters level licensed behavioral health professional- LCSW, LPC, LMFT). CEAP certification as required by management. IMPORTANT!
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