Utilization Management Clinician - Behavioral 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
Minimum Qualifications:
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.
Accountabilities:
Job Performance/Responsibilities:
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.
Job Description: Utilization Management Behavioral Clinician Page 3 of 3
Customer Services-Internal:
Supports a positive working environment;
Identifies and resolves potential personnel/peer problems and
issues proactively, readily utilizing the Director of Behavior
Utilization Management as a resource;
Communicates to Director of Behavioral Utilization Management all
problems, issues and/or concerns as they arise;
Communicates to the Director of Behavioral Utilization Management
any issues or concerns related to quality of care, using the Health
Integrated procedure;
Maintains a courteous and professional attitude when working with
all Health Integrated staff members and the management team; and
Actively participates in team meetings, as designated.
Customer Service-External:
Timely identifies and communicates to applicable practitioners,
providers and the health purchaser staff all issues and concerns
related to the case at hand;
Communicates to the client/health plan staff any issues or concerns
related to quality of care, using Health Integrated
policies/procedures.
Works, communicates and collaborates in harmony and in a
courteous and professional manner with the patient, practitioner,
provider and multidisciplinary health care team members all issues,
concerns and/or as the UM Plan is revised and/or new services are
implemented/terminated;
Serves as a liaison and patient advocate when deemed applicable
for quality of care and cost outcomes; and
Communicates appropriately and according to policy, and/or
regulatory requirements with the practitioner(s), provider(s),
patient/patients legally appointed representative any UM coverage
determination(s).

Location:	Tampa, FL United States