The UM Clinical Specialist-Behavioral Health performs professional and administrative work, primarily utilization reviews, utilization management and active care management to ensure economical and effective consumer service delivery by PHIP enrolled network providers; The position is responsible for providing medical necessity reviews of individualized service plans and requests for authorization of services to ensure consumers receive services in the least restrictive, most integrated setting appropriate to the individual’s needs; The primary role is to review for services under the Medicaid B waiver and state funded benefits; complete related work as required.
This position is full-time remote. The selected candidate must reside in North Carolina. Some travel for onsite meetings may be required.
Responsibilities & Duties
Utilization Reviews and Management
- Independently conducts medical necessity reviews of service requests submitted by service providers against developed clinical guidelines within contractually mandated turn-around times
- Conducts utilization reviews to monitor adherence to clinical practice guidelines and best practice standards and to determine if services were delivered as requested
- Engage in care management activities to ensures individuals receive appropriate referral for treatment including; consumer and provider follow-up calls, case staffing with psychologists and medical staff
- Monitors consumer person centered plans to ensure that effective treatment interventions are utilized, provide consultation to treating providers when person centered plan requires adjustments to better meet consumer needs
- Monitors and reports consumer and provider specific over/under utilization
- Conducts utilization reviews to monitor for over/under utilization
Program Operation and Management
- Identify high risk consumers and those with special health care needs for referral to Care Coordination and case escalation
- Provides linkage, authorizations and level of care determinations, assisting providers and Care Coordinators with creative problem solving to recommend alternative approaches to care
- Ensures compliance with care management and quality improvement policies and procedures, utilization review laws and regulations, state standards
- Promote access to appropriate, effective and quality treatment
- Monitors for undesirable performance or deviations of practice standards through care management activities that may have a negative impact on consumers. Responds through additional follow-up with consumer and providers, provider technical assistance and/or referral to other departments within the MCO
Administrative Functions
- Notifies members of adverse benefit determinations while preserving members’ Due Process rights
- Engages in routine follow-up to ensure consumers are engaged in treatment and services are being delivered as requested
- Documents utilization review decisions in computerized authorization management system
- Maintain professional licensure
- Engages in training as needed to stay informed of changes in best practice for supporting the needs of individuals with MH/SUD/IDD
Minimum Requirements
Education & Experience
Required:
Master’s degree in a Human Services field (such as Psychology, Social Work or Counseling) and at least five years of post-degree progressive experience providing similar services to the population served (MH/SUD).
Requires current and active license issued by a North Carolina Professional Board, as a LCSW, LCAS, LP, LPA, LMFT, LCMHC or RN.
OR
A master's degree in psychiatric nursing which provides the knowledge, skills, and abilities needed to perform this work; or graduation from a State accredited school of nursing and two years of experience in psychiatric nursing which provides the knowledge, skills, and abilities needed to perform the work; or an equivalent combination of education and experience.
Preferred:
Experience in the public behavioral healthcare field is highly desired due to the complexity of the work. Experience in a UM environment in Behavioral Healthcare would be valuable for this employee.
Knowledge, Skills, & Abilities
- Considerable knowledge of case management principles, practices and applications
- Considerable knowledge of agency and community programs and services which affect clients and applicants
- Knowledge of state and federal client rights protection statues and regulations applicable laws and regulations including but not limited to URAC, applicable Code of Federal Regulations and NC Administrative Code
- Effective written and oral communication skills and interpersonal and presentation skills
- Ability to identify rights protection complaint issues; ability to set, monitor and evaluate standards for quality and to assess plans to measure how they meet the needs of individual clients
- Considerable knowledge in DMS 5 diagnostic criteria
- Ability to manage time, prioritize work and use problem-solving approaches
- Ability to coordinate effectively with staff from a various agency as well as inter-departmental
- Ability to read, analyze, and interpret regulations, policies and procedures
- Coordinate work with a variety of individuals and agencies
- Ability to operate computer equipment and generate reports and records; ability to express ideas clearly and concisely orally and in written documents
- Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) is required
Salary Range
$68,227 -$86,990/Annually
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity
An excellent fringe benefit package accompanies the salary, which includes:
- Medical, Dental, Vision, Life, Long Term Disability
- Generous retirement savings plan
- Flexible work schedules including hybrid/remote options
- Paid time off including vacation, sick leave, holiday, management leave
- Dress flexibility
