Position Purpose: Manage clinical services to include management of clinical services, marketing of clinical services and supervision of clinical staff.
- Manage clinical services including oversight of clinical policies and procedures, day to day clinical services and staff
- Ensure compliance with established initial and concurrent review, case management, referral, pre-certification and authorization policies, procedures and processes
- Ensure all programs and clinical operations are in full compliance with state and federal regulations. Including HIPAA
- Ensure compliance with plan’s emergency management policies, procedures and processes by acting as liaison with other business units
- Ensure payer contract clinical deliverables are met
- Monitor the effectiveness of existing procedures and outreach/intervention efforts
- Ensure appropriate knowledge/education and interventions are conducted for members defined to be at risk
- Monitor data to address trends or potential quality improvement opportunities including provider issues, service gaps, member needs
Additional Responsibilities for New Hampshire:
- Oversee the implementation and maintenance of the provider training program for community agencies. Collaborate with network development team to track and analyze needs and recommend training plans
- Act as liaison with provider and community agencies, including state hospital facilities, Community Mental Health Centers (CMHC) and various providers, foster care system and community organizations
Education/Experience: Master’s degree in behavioral health or RN required. 3-5 years case and/or utilization management. Thorough knowledge in assessment, diagnosis and treatment of individuals with general mental health or substance abuse disorders. Knowledge of utilization review procedures, case management and familiarity with mental health community resources. 2-3 years supervisory experience preferred.
Knowledge/Experience for New Hampshire:
Master’s degree in Behavioral Health or related field or RN license required. 8+ years of case and/or utilization management experience, including demonstrated experience both in the provision of direct care services as well as progressively increasing levels of management responsibilities, with a particular focus on direct care and administrative responsibilities within community mental health services.