Position Purpose: Perform duties to authorize and review utilization of mental health and substance abuse services provided in inpatient, outpatient and intermediate care settings, provide and/or review intakes and initial evaluations, brief focused treatment interventions, monitor quality of care, collect and analyze utilization and cost of care data, assist with discharge planning, arrange transportation; provide member assistance and participate in special utilization projects.
Authorize, direct and monitor care for mental health and substance abuse problems according to clinical information given by providers and internal criteria for medical necessity and appropriateness of care.
Ensure compliance with all performance measures in regards to appeals, denials, higher level of care admission certification and concurrent review timeliness, Outpatient Treatment Report review timeliness, readmissions, and others as indicated.
Interact with physicians and social workers for discharge planning.
Direct and coordinate follow-up to ensure plans for continuity of care and adherence to HEDIS standards.
Compile and report daily review activity and facility statistics.
Participate in quality improvement activities, supporting network development and interfacing with treatment facilities and the professional community.
Verify subscriber eligibility and existing benefits for mental health and substance treatment, prior to authorizing all levels of treatment including concurrent outpatient.
Track benefit usage and advise appropriate parties of exhaustion of benefits.
Interact with Medical Director or designee to discuss clinical authorization questions and concerns regarding specific cases.
Education/Experience: Master's degree in Behavioral Health or RN. 3+ years experience in psychiatric and/or substance abuse health care settings including utilization review. Working knowledge of utilization review procedures, mental health and substance abuse community resources and network providers.