Under general supervision, and in collaboration with other members of the clinical team, authorizes and reviews utilization of mental health and substance abuse services provided in inpatient and intermediate care settings. Collects and analyzes utilization data. Assists with discharge planning and ambulatory follow up activity. Provides member assistance with mental health and substance abuse issues, and participates in special quality improvement projects.
- Monitors inpatient and intermediate level of care services related to mental health and substance abuse treatment to ensure medical necessity and effectiveness.
- Provides telephone triage, crisis intervention and emergency authorizations as assigned.
- Performs concurrent reviews for inpatient care and other levels of care as allowed by scope of practice and experience. In conjunction with providers and facilities, develops discharge plans and oversee their implementation.
- Provides information to members and providers regarding mental health and substance abuse benefits, community treatment resources, mental health managed care programs, and company policies and procedures, and criteria.
- Interacts with Physician Advisors to discuss clinical and authorization questions and concerns regarding specific cases.
- Participates in quality improvement activities, including data collection, tracking, and analysis.
- Maintains an active work load in accordance with National Care Manager performance standards. Works with community agencies as appropriate. Proposes alternative plans of treatment when requests for services do not meet medical necessity criteria. Participates in network development including identification and recruitment of quality providers as needed. Advocates for the patient to ensure treatment needs are met. Interacts with providers in a professional, respectful manner that facilitates the treatment process.
Masters (Required), Masters (Required)
License and Certifications - Required
CEAP - Certified Employee Assistance Professional - Care Mgmt, LCSW - Licensed Clinical SocialWorker - Care Mgmt, LMSW - Licensed Master SocialWorker - Care Mgmt, LPC - Licensed Professional Counselor - Care Mgmt,LPN -Licensed Practical Nurse- Care Mgmt, PSY - Psychologist - Care Mgmt
License and Certifications - Preferred
Other Job Requirements
Licensure is required for this position, specifically a current license that meets State, Commonwealth or customer-specific requirements.
Minimum of 6 years post-degree experience in psychiatric and substance abuse health care.
Minimum of 3 years post degree experience for Care Managers with Ph.D. Experience to include utilization review.
Licensure may also include one or more of the following: CEAP, LMSW, LCSW or LPN. CEAP certification as required by management.
Strong organization, time management and communication skills.
Knowledge of utilization management procedures, mental health and substance abuse community resources and providers.
Knowledge and experience in inpatient setting.
Knowledge of DSM V or most current diagnostic edition.
Ability to analyze specificutilization problems, planand implement solutions that directly influence quality of care.