Under the general supervision of the Manager Clinical Services, or Supervisor Care Management, and in collaboration with the other members of the clinical team, the incumbent authorizes and reviews utilization of mental health and substance abuse services provided in inpatient and intermediate care settings; collects and analyzes utilization data; under the direction of the supervisor or Medical Director, assists with discharge planning and ambulatory follow up activity; provides member assistance with mental health and substance abuse issues, and participates in special QI projects. Manage a caseload of ICM members if assigned.
Monitor inpatient and intermediate level of care services related to mental health and substance abuse treatment to ensure medical necessity and effectiveness.
Provide telephone triage, crisis intervention and emergency authorizations as assigned.
In conjunction with providers and facilities, develop discharge plans and oversee their implementation
Perform concurrent reviews for inpatient care and other levels of care as allowed by scope of practice and experience.
Provide information to members and providers regarding mental health and substance abuse benefits, community treatment resources, mental health managed care programs, and Magellan Health Services policies and procedures, and criteria.
Interact with Physician Advisors to discuss Clinical/authorization questions and concerns regarding specific cases.
Participate in QI activities, including data collection, tracking, and analysis.
TRF’s to be reviewed by Master’s level Care Manager only. RN’s may perform all other related duties.
Maintain an active work load in accordance with National Care Manager performance standards; Work with community agencies as appropriate; Propose alternative plans of treatment when requests for services do not meet medical necessity criteria; Participate in network development including identification and recruitment of quality providers as needed; Advocate for the patient to ensure treatment needs are met. Interact with providers in a professional, respectful manner that facilitates the treatment process.
Licensure required: State independent behavioral health licensure
Education: Master’s Degree in behavioral health field
Field(s) of study: Masters or Doctoral Degree in behavioral health related field
Experience: 3-5 years
Industry: Managed Care
Job Specific: 3 yrs experience post degree in psychiatric and/ or substance abuse health care setting, including utilization review. Associate Care Manager must have performance ratings of “meets expectations” or “exceeds expectations” in order to qualify for this position.
Other: Good 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; ability to function independently and as a team member; knowledge of DSM IV or most current diagnostic edition. Ability to analyze specific utilization problems, plan and implement solutions that directly influence quality of care.
Computer Skills: Ability to use computer systems
Associates: Nursing (Required),Bachelors: Social Work (Required), Masters: Social Work (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,RN -Registered Nurse, State and/or Compact State Licensure - 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.
One or more of the following licensure is required for this role with necessary degrees: CEAP, LMSW, LCSW, LPC, RN or LPN.
Minimum 2 years experience post degree in healthcare, behavioral health, psychiatric and/or substance abuse health care setting.
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 and/or outpatient setting.
Knowledge of DSM V or most current diagnostic edition.
Ability to analyze specific utilization problems, plan and implement solutions that directly influence quality of care