Provides behavioral health care management services through prospective, concurrent and retrospective evaluation and review of treatment. Determines medical necessity, level of care required and quality of care provided. Coordinates and manages behavioral health services rendered by network and non-network providers to health plan members using InterQual criteria, clinical skills and expertise, persuasive communication and access to care standards to promote cost-effective quality outcomes. Oversees and coordinates all facets of care management including initial contacts, necessary triage, pre-certification, administrative and clinical concurrent review, discharge and aftercare planning/referrals and linkage of patients to appropriate mental health providers and outside agencies for follow-up care.
DEPARTMENT: Health Services-Utilization Management
REPORTS TO: Supervisor, Behavioral Health UM
- Performs behavioral health triage and crisis management services. Links and coordinates services with medical/surgical departments and other outside agencies, such as transportation and home health care. Coordinates psychiatric diagnoses, behavioral health treatment services, and psychotropic medications with behavioral health providers and physician advisors. Refers members to the appropriate level care and reviews and authorizes care services using InterQual criteria and medical necessity guidelines. Documents treatment authorizations and monitors, tracks and reports behavioral health care utilization.
- Conducts all necessary direct utilization management activities for behavioral health plan members including service coordination for members in crisis, crisis intervention, behavioral health triage, crisis assessment services, pre-certification and authorization of care for both psychiatric and chemical dependency services, all necessary concurrent review with hospitals and mental health centers, discharge and aftercare planning and referrals for continued outpatient care.
- Interacts on a daily basis with hospital representatives and attending psychiatrists and coordinates physician-to-physician reviews with the medical director. Reviews treatment plans and consults with medical director regarding medical necessity criteria for continued inpatient stay. Facilitates community placements, agency linkages and coordinates discharge planning, aftercare, referral and follow-up of inpatients.
- Documents, monitors, tracks, and reports authorizations, denials, treatment plans, clinical findings, progress notes, and case dispositions related to behavioral health services using automated and manual systems and formats.
- Monitors, tracks and reports cases. Monitors utilization trends by hospital and attending psychiatrist with emphasis on managing high volume providers.
- Identifies high risk/high volume members for more intensive follow-up care and conducts hand-off coordination between Clinical Coordinators and providers.
- Coordinates community resources with emphasis on the development of natural support system. Coordinates benefits, regulations, laws and public entitlement programs. Applies psychological and counseling theory and industry standard clinical guidelines with the appropriate ICD-9/DSM IV diagnosis. Maintains HIPAA standards and confidentiality of protected health information. Reports critical incidents and information regarding abuse and neglect.
- Ensures members have access, availability and quality care according to standards.
- Participates in case conferences regarding high risk/high volume regarding provider and hospital issues. Attends and participates in other HBH work groups and meetings as required.
- Responds to incoming telephone calls as assigned, meeting or exceeding the standards for phone access and availability in order to meet the needs of members served by the department.
- Performs all other clinical and administrative duties as assigned.
*LI-SM1 Candidate Education:
- Required a Bachelor's Degree in nursing (if RN)
- Required or equivalent work experience (if RN) beyond 2 years
- Required a Master's Degree in clinical social work, psychology, counseling, rehabilitation etc. (if LSCW)
- Required 2 years of experience in a clinical/hospital setting using stated criteria
- Required 1 year of experience in clinical behavioral health experience providing direct patient care services
- Preferred experience providing care management or utilization management services in a managed behavioral health organization, community mental health center, health plan or hospital
- Required knowledgeable of and comply with state and federal statutes, rules and policies that affect the members
Licenses and Certifications:
- Intermediate ability to create, review and interpret treatment plans
- Intermediate ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Intermediate demonstrated written communication skills
- Intermediate ability to effectively present information and respond to questions from families, members, and providers
- Intermediate ability to provide crisis intervention services to members under the supervision of the medical director
- Intermediate ability to effectively present information and respond to questions from peers and management
- Intermediate knowledge of healthcare delivery
A license in one of the following is required:
- Required Licensed Registered Nurse (RN)
- Required Licensed Clinical Social Worker (LCSW)
- Required Licensed Clinical Marriage & Family Therapist (LCMFT)
- Required Licensed Clinical Mental Health Counselor (LCMHC)
- Required intermediate Microsoft Outlook
- Ability to communicate on any level required to meet the demands of the position
- Required intermediate Microsoft Word
- Required intermediate Microsoft Excel
- Ability to define problems, collect and interpret data, establish facts, draw valid conclusions and process work to completion
- Preferred intermediate Microsoft Access
- Bi-lingual (Spanish and English) capabilities in reading, writing and speaking preferred
- Required intermediate Healthcare Management Systems (Generic)