Health Services - Spec, Utilization Management

Utilizing key principles of utilization management, the Behavioral Health Utilization Management Specialist will perform prospective, concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage. Leveraging clinical expertise and critical thinking skills, the Behavioral Health Utilization Management Specialist, will analyze clinical information, contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements contribute to determination of appropriateness and authorization of clinical services both medical and behavioral health.

ESSENTIAL FUNCTIONS:50% Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, Client's Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all Client's lines of business to include Commercial, FEP, and Medicare primary and secondary policies.

30% Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts to assist with benefit determination.

20% Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care. Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.

QualificationsTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonableaccommodations may be made to enable individuals with disabilities to perform the essential functions.

Education Level: Master's DegreeEducation Details: Psychology or Social WorkExperience: 5 years Clinical experience required2 years Care Management preferred

In Lieu of Educationn/a - education/licensure is requirement

Preferred QualificationsWorking knowledge of managed care and behavioral health delivery systems.Thorough knowledge of Client's clinical guidelines, medical policies and accreditation and regulatory standardsWorking knowledge of Client's IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource.Experience in direct treatment of both substance use and mental health focused treatment.

Knowledge, Skills and Abilities (KSAs)Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues, ProficientMust have strong assessment skills with the ability to make rapid connection with Member telephonically., ProficientMust be able to work effectively with large amounts of confidential member data and PHI, ExpertMust be able to prioritize workload during heavy workload periods, ProficientAbility to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility, AdvancedProficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint, ProficientExcellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis, Proficient

Licenses/CertificationsLCPC – Licensed Clinical Professional Counselor – MD, DC, or VA license requiredLCSW-C - Licensed Clinical Social Worker – MD, DC, or VA license required

*Business Justification: BH um specialist is required to staff upcoming change to begin prior authorization of outpatient behavioral health services which are not managed currently.

Additional Skills:Excel database filtering/useKnowledge of multiple modalities of mental health service deliveryLicensed in MD, DC or VA.

Talteam Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.