Utlization Management Specialist $6K Bonus!

Utilization Management Specialist 

POSITION SUMMARY:                     

Under supervision of the Care Management Supervisor, monitors appropriate uses of Saginaw County Community Mental Health Authority (SCCMHA) resources for treatment and support of individual episodes of care, coordination of care and adequacy of supports and services to sustain outcomes.  This position uses best practice that are derived from scientific evidence to bring together health care resources from across the continuum of care in the most appropriate, effective, and efficient manner to care for the client Specific duties in utilization review may be assigned within individual staff scope of practice and target population expertise.  Performs responsibilities and tasks with a demeanor and attitude that promotes goodwill, builds positive relationships, communicates respect for human dignity and contributes positively to the mission and values of SCCMHA.  This position will be knowledgeable about and actively support culturally competent recovery-based practices; person centered planning as a shared decision-making process with the individual, who defines his/her life goals and is assisted in developing a unique path toward those goals; and a trauma informed culture of safety to aid consumer in the recovery process.    

ESSENTIAL DUTIES AND RESPONSIBLITIES:

1.    Provides preauthorization of services based on review of assessments and the medical record for evidence of medical necessity and within the definition of the benefit.  Acts on behalf of the client to assure that necessary clinical services are received and that progress is being made. If denial of service is indicated this position will review pending denial in multidisciplinary Care Conference. If denial or reduction of service is supported in conference, will ensure due process of Adequate or Advanced notice to the consumer.  

2.    Works closely with the Central Access and Intake unit to facilitate eligibility assessment, referral and team assignment for new consumers.  

3.    Reviews level of functioning assessments including CAFAS, LOCUS, SIS, ASAM and others as implemented by SCCMHA and decides on appropriate level of care placement for mental health and substance use treatment services.

4.    Works in multiple electronic health record systems with the ability to ensure data integrity and accurate data interface between systems. 

5.    Provides concurrent review of community-based services and works as a team member with utilization management tasks related to management of the entire behavioral health benefit.  These services include, but are not limited to, assessment, care planning, education, referral, advocacy, monitoring, and periodic reassessment. Brief therapy, Enhanced Services and Supports Coordination and ACT.  Episodes of care may be selected for sample review or flagged for review due to under or over utilization or due to inadequate documentation in the person-centered plan and supporting assessments.  Concurrent review of services includes review of assessment and plan for concurrence with Service Selection guidelines and protocols, consultation with primary care provider and/or consumer, and may include written recommendations to the provider and consumer incorporating suggestions for modifications in the plan. 

6.    Through concurrent review, may recommend the denial of authorization or reauthorization of service or may suggest reduction in the quantity or duration of services.  If reduction or denial of service is recommended, will review the proposed reduction or denial in multidisciplinary Care Conference.  If denial or reduction of service is supported in conference, will ensure due process of Adequate or Advanced notice to the consumer.

7.    Prepare written justification of denial with suggestions for alternative resources when denying services through preauthorization review or concurrent utilization review documentation.  

8.    May issue recommendation for provider restitution of payments if documentation of eligibility is not complete or adequate to support eligibility certification in the medical record.

9.    Prepares individual utilization profile analysis reports and makes recommendations for primary care providers.  Profile preparation includes data analysis, record review and written analysis and recommendations. 

10.    Conduct provider training in Care Management Policies and procedures, service selection guidelines, eligibility assessment criteria, severity of illness/intensity of service requirements, coordination of care standards, service protocols and utilization management performance indicators.   Training may also be provided to other groups including Citizens Advisory Committee, community groups and others as requested by the Director of Care Management and Quality Services.  The role of through these trainings will be to reduce the incidence of denial or reduction of service decisions.  

11.    Participates in multidisciplinary Care Conference for the review of all adverse decisions and individual and provider profile review and related care management performance indicators.

12.    Participates in process improvement committees as assigned, including preparation of summaries of findings for review by supervisory staff.

13.    Is responsible for accurate and timely codification and entry of data and writing of reports, communication of decisions to providers and consumers. 

14.    Preserves confidentiality of information accessed in performance of assigned duties.

15.    Uses supervision to resolve areas of performance concerns and to facilitate professional growth and development.

16.    Adheres to the mission, vision, core values and operating principles of SCCMHA at all times.

INCIDENTAL DUTIES AND RESPONSIBILITES:

1.    Works closely with and coordinates efforts with those of information systems and administrative staff.

2.    May attend meetings; make presentations to groups and/or in-service personnel or contractors.

3.    May attend workshops, seminars or meetings, read journals, periodicals and research subjects on the Internet to maintain professional proficiency and disseminate information.

4.          Must react productively to change and handle other essential tasks as assigned.

 (The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all duties and responsibilities required of personnel so classified.)

REPORTING RELATIONSHIPS:

Reports to:    Care Management Supervisor

Supervises:    None

WORKING CONDITIONS/ENVIRONMENT:

Works in an office environment with normal time constraints and pressures.  Uses a work station, keyboard and views a computer screen for long periods, uses telephone and headset. Carries a pager during business hours.  May involve travel to multiple service locations.

QUALIFICATIONS:

Education:     Master’s degree in a mental health related field from an accredited school required.  

Experience:    A minimum of five (5) years progressive experience in preferably diverse treatment settings including: psychiatric inpatient, outpatient, managed care, and case management.  Consideration of experience and scope of practice will be uniquely considered for each team vacancy as the agency requires a team which enables us to manage a wide range of special needs populations (developmental disabilities, substance abuse, VA, children’s, mentally ill and medical health specifically in a hospital setting and/or medical clinic.) and determined in interviews, with depth and range given more preference.

Licenses and Certifications:    Valid Michigan Driver’s license with a good driving record.  

Must be able to apply and obtain a limited licensed master’s social worker (LLMSW), licensed master’s social worker (LMSW), limited licensed professional counselor (LLPC), licensed professional counselor (LPC), limited licensed marriage and family therapist (LLMFT), licensed marriage and family therapist (LMFT), limited licensed psychologist (LLP) and licensed psychologist (LP).   Must have or obtain a certification in substance use treatment specialist area.

Knowledge, Skills, and Abilities:    

1.    Demonstrated competency in scope of practice as social worker.

2.    Posses’ knowledge of healthcare benefits. 

3.    Professional level verbal and written communication skills.

4.    Ability to produce accurate and comprehensive work products with minimal direction.

5.    Ability to exercise mature judgment and maintain strict confidentiality.

6.    Ability to maintain favorable interpersonal working relationships and positive public relations.

7.    Ability to plan and organize work, perform tasks consistently and adhere to priorities.

8.    Ability to provide small group leadership.

9.    Ability to assess and diagnosis chemical dependency. Knowledge of chemical dependency, ASAM and mental health best practice.

Physical/Mental Requirements:    

1.    Hearing acuity to converse in person and on telephone.

2.    Visual Acuity to observe consumers behavior, read and proofread documents and use CRT.

3.    Ability to walk, stand or sit for extended periods of time.

4.    Manual dexterity to write and to operate standard office equipment (PC, Keyboard, Copy Machine, Fax Machine, etc.)

5.    Ability to lift and carry files and supplies at least 20 pounds.

6.    Strong interpersonal skills to interact with leadership, employees, consumers and the general public.

7.    Analytical skills necessary to conduct research, analyze, and interpret complex data and identify and solve problems by proposing courses of action.

8.    Ability to plan short and long range and to manage and schedule time.

9.    Ability to handle stress in meeting deadlines and dealing with large numbers of employees and/or consumers.

(Listed qualifications are for guidance in filling this position. Any combination of education and experience that provides the necessary knowledge, skills, and abilities will be considered; however, mandatory licensing or certification requirements cannot be waived. Physical/mental requirements cannot be waived unless specifically indicated.)