Behavioral UM Clinician Health Integrated
JOB SUMMARY: The Utilization Management Clinician is responsible for conducting utilization and quality management activities in accordance with Utilization Management policies and procedures. The position responsibilities include the management of medical costs through timely prospective, concurrent and retrospective review activities.
CORE COMPETENCIES: Patient Relations, Care Management, Contributing to Team Success, Managing Work (including Time Management), Quality Orientation
Education/License/Certification: Licensed healthcare professional (RN, LCSW, LMHC, LMFT, PsyD) with a current, unrestricted license required.
Experience: One to two years of experience in utilization review, quality assurance, discharge planning or other cost management programs preferred. One to two years directly related experience using InterQual criteria or healthcare criteria preferred. Two (2) years experience in direct patient care required. Behavioral health experience in multiple levels of care for Behavioral Health Utilization Management preferred. Call center knowledge desirable.
Knowledge/Skills: Strong communication, documentation, clinical and critical thinking skills essential; Working knowledge of utilization management/case management preferred; Strong problem solving and decision making skills essential; Strong typing and computer skills essential.
Contributes to UM program goals and objectives in containing health care costs and maintaining a high quality medical delivery system through the program procedures for conducting UM activities;
Performs telephonic review for inpatient and outpatient services using InterQual criteria or Health Integrated behavioral health criteria;
Collects only pertinent clinical information and documents all UM review information using the software system;
Promotes alternative care programs and researches available options including costs and appropriateness of patient placement in collaboration with health plan clients;
Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services;
Communicates with the designated medical director regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues;
Recommends, coordinates and educates providers regarding alternative care options;
Maintains an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital and health plan client discharge planners and social workers in the early identification of potential home care candidates or less restrictive level of care placement;
Participates in UM program CQI activities;
Communicates all UM review outcomes in accordance with the health plan client profile procedures;
Follows relevant client time frame standards for conducting and communicating UM review determination;
Maintains and submits reports and logs on review activities
Identifies and communicates to the Director of Behavioral Utilization Management all hospital, ancillary provider, physician provider and physician office concerns and patient safety issues;
Identifies and communicates to the Director of Behavioral Utilization Management supervisor all potential quality of care concerns;
Serves as liaison for provider staff and the health plan client;
Maintains courteous, professional attitude when working with all staff, hospital and physician providers, and health plan client;
Identifies and communicates to health plan client and/or contracted ancillary providers all catastrophic and high risk cases for case management referral;
Active participation in team meetings; and
Performs other duties as requested by the Director of Behavioral Utilization Management or supervisor of Behavioral Health.
Are readily available to answer questions of the non-clinical staff and shall ensure that non-clinical staff is performing within the scope of the non-clinical role.
Offer input and assistance with development and delivery of orientation, education and training programs.
Makes suggestions on program development to ensure effectiveness, quality, productivity, profitability and patient safety.
Consults and seeks advise from licensed physician and/or medical director with expertise appropriate to the type of services being managed.
||10008 North Dale Mabry |
Tampa, FL 33618