Summary:
We are seeking a highly motivated and experienced Care Manager, with Behavioral Health experience. The Care Manager is responsible for the oversight and review of Behavioral Health Treatment (BHT) including Applied Behavior Analysis (ABA) services offered to eligible members. The Care Manager will screen, triage and assess members to determine the appropriate level of care based on medical necessity criteria. The Care Manager will review and process requests for authorization of BHT services from behavioral health providers. They are also responsible for utilization management, quality reviews and monitoring activities of BHT services. The Care Manager will directly interact with providers for care coordination for BHT/ABA services.
Duties & Responsibilities:
- Care Management Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
- Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
- Reviews requests for medical appropriateness.
- Verifies and processes referrals using established clinical protocols to determine medical necessity.
- Screens requests for the Medical Director's review, gathers pertinent medical information prior to submission to the Medical Director, follows up with the requester by communicating the Medical Director's decision and documents follow-ups in the utilization management system.
- Completes required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates.
- Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the line of business.
- Performs quality review of submitted documents and ensures the required elements are met by the established protocols, policies and procedures.
- Mails rendered decision notifications to the provider and member, as applicable. Adheres to utilization management regulations and processing timeframes.
- Meets productivity and quality of work standards on an ongoing basis. Identifies potential quality issues and fraud/waste/abuse and reports timely to appropriate department.
- Stays up to date with federal, state and local regulations that pertain to the BHT benefit. Assists with case audits as assigned.
- Completes care coordination activities as assigned.
- Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
- Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
- Reviews requests for medical appropriateness.
- Verifies and processes referrals using established clinical protocols to determine medical necessity.
- Screens requests for the Medical Director's review, gathers pertinent medical information prior to submission to the Medical Director, follows up with the requester by communicating the Medical Director's decision and documents follow-ups in the utilization management system.
- Completes required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates.
- Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the line of business.
- Performs quality review of submitted documents and ensures the required elements are met by the established protocols, policies and procedures.
- Mails rendered decision notifications to the provider and member, as applicable.
- Adheres to utilization management regulations and processing timeframes.
- Meets productivity and quality of work standards on an ongoing basis.
- Identifies potential quality issues and fraud/waste/abuse and reports timely to appropriate department.
- Stays up to date with federal, state and local regulations that pertain to the BHT benefit.
- Assists with case audits as assigned.
- Completes care coordination activities as assigned.
- Completes other projects and duties as assigned.
Qualifications:
Minimum
- Master's degree in psychology, social work, counseling or related field required.
- 4 years of experience providing ABA and or mental health services, including experience in clinical review and treatment plan oversight.
- An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
Preferred
- Prior authorization/utilization review experience.
- Managed care experience.
- Post degree ABA experience.
- Quality assurance experience.
Required Licensure / Certifications:
- Current CA unrestricted license such as LCSW, LPCC, LMFT, RN (with BH experience), Board Certified Behavioral Analyst (BCBA) or Board-Certified Behavior Analyst - Doctoral (BCBA-D).
Knowledge & Abilities:
- Develop rapport and establish and maintain effective working relationships with leadership and staff and external contacts at all levels and with diverse backgrounds.
- Work independently and exercise sound judgment.
- Communicate clearly and concisely, both orally and in writing.
- Work a flexible schedule; available to participate in evening and weekend events.
- Organize, be analytical, problem-solve and possess project management skills.
- Work in a fast-paced environment and in an efficient manner.
- Manage multiple projects and identify opportunities for internal and external collaboration.
- Motivate and lead multi-program teams and external committees/coalitions.
- Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Physical Requirements (With or Without Accommodations):
- Ability to visually read information from computer screens, forms and other printed materials and information.
- Ability to speak (enunciate) clearly in conversation and general communication.
- Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
- Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
- Lifting and moving objects, patients and/or equipment 10 to 25 pounds
Work Environment:
- Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
- There are no harmful environmental conditions present for this job.
- The noise level in this work environment is usually moderate.
Shift: Monday - Friday; 8:00 am - 4:30 pm
Contract Length: 6 months to 1,000 hours
Equiliem Healthcare
specializes in staffing clinical, non-clinical, and allied personnel. We excel in all levels, disciplines, and specialties within the healthcare spectrum. Our projects range from short to long term local and travel assignments. Equiliem has been recognized as a certified small business enterprise. In addition, we are proud that we have earned the prestigious Joint Commission accreditation for staffing firms and have been awarded Best in Staffing 4 years running by our employees and client partners.
Benefits offered to our workers include the following:
- Medical Insurance
- Vision & Dental insurance
- Life Insurance
- 401K
- Commuter Benefits
- Employee Discounts & Rewards
- Payroll Payment Options
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Equiliem
medical insurance, dental insurance, life insurance, 401(k)
Nov 10, 2024