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/or outpatient care settings. Collects and analyzes utilization data. Assists with discharge planning and care coordination. Provides member assistance with mental health and substance abuse issues, and participates in special quality improvement projects.
- Monitors inpatient and/or outpatient 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 and/or outpatient care and other levels of care as
allowed by scope of practice and experience. In conjunction with providers and facilities,
may develop discharge plans and oversee their implementation. May also perform quality
clinical reviews while educating and making appropriate interventions to advance the care of
the member in treatment.
- 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
- 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.
- Independent behavioral health licensure: LPC, LCSW
- Master's degree in behavioral health or other related field
- Two year's clinical work experience
- 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.
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.