Utilization Care Manager

Hours: M-F Days

Part Time: 20 hours/week

General Summary

Performs a variety of reviews and applies utilization and case management techniques to determine the most efficient use of resources to support the provision of appropriate, cost effective and quality treatment. Assists in the organizing of utilization reports and revision of clinical policies and procedures as required.

Duties and Responsibilities

• Performs initial reviews for medical necessity and appropriateness of setting for the assigned case load.
• Conducts concurrent reviews to ensure medical necessity for continued hospitalization and initiates problem-solving techniques as needed to prevent over and/or under utilization.
• Liaisons with the treatment provider regarding the identified treatment plan in accordance with concurrent review criteria.
• Assists the treatment provider in identifying and coordinating alternative, least restrictive settings that will provide appropriate and qualitative care while controlling cost.
• Identifies conditions that require case management across the member's episode of treatment or between treatment episodes. Collaborates with the treating provider to identify the member's needs including those beyond the immediate clinical treatment administered by the provider.
• Coordinates services with medical utilization/care management personnel of other health plans to ensure appropriate, cost effective treatment and identify areas where both utilization management personnel can collaborate.
• Assists with the collection and analysis of utilization data and tracks ongoing care management cases and their outcomes.
• Brings known or suspected problems of under-, over-, or inappropriate utilization of resources to the attention of the appropriate manager(s).
• Prepares and maintains appropriate documentation as required.

Common Expectations:

• Maintains established policies and procedures, objectives, quality assessment and safety standards.
• Enhances professional growth and development through participation in educational programs, current literature, inservice meetings, and workshops.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Prepares and presents utilization data analysis as required.

Qualifications

Minimum Education:

• Masters Degree In Psychology or Social Work. Required
• Doctorate of Philosophy (Ph.D.) Preferred or
• Doctorate Psy.D. Preferred

Work Experience:

• 5 years Post graduate experience as a provider of behavioral health treatment services. Required and
• Previous quality assessment and utilization management experience. Required
• Experience with Critical Incident Stress Management (CISM) Required
• Experience providing and implementing trainings

Licenses:

• Licensed Social Worker Upon Hire Required or
• Licensed Psychologist Upon Hire Required or
• Licensed Registered Nurse with Psychiatric Certification Upon Hire Required

Knowledge, Skills, and Abilities:

• Good communications skills and organizational skills.