Utilization Manager

Description

The Utilization Manager will develop authorizations with MCOs.  This position will serve as liaison between the Utilization Department and Lead Therapist, Therapist, and Case Managers and will work closely with the Service Coordinators in order to ensure continuity of care and quality of service to consumers.  The UM will have excellent communication and documentation skills and possess an understanding of all mental health and development services.  This position plays an active part in the interdisciplinary team.  

Requirements

Responsibilities:  

• Ensure Client Rights are being adhered by for all consumers. 
• Responsible for attending to all the rules and regulations of the agency, state, and federal statues, and attending rules of quality improvement, medical records, finance, etc. of the agency (including delivery of service to consumers under best practice models). 
• Submit Initial and Concurrent Authorizations to MCOs for assigned contract areas by completing/updating authorization requests forms as needed. 
• Document work, Update and maintain trackers (ICAN, Referral, Master tracker) such as upcoming due dates, units etc.) supplied by supervisor and submit to necessary parties as required by supervisor 
• Verify client insurance coverage for authorization submission 
• Coordinate with MCO to resolve documents issues submitted for authorizations  
• Gather and Review accuracy and complete all referral forms, intake forms, ICAN/Screenings forms prior to submitting to MCO. 
• Communicate with program managers when authorizations are completed, and clients are ready to be billed.  Provide program mangers electronic copy of ICANs. 
• Track and review ICANs/Screening scores for accuracy all new clients for completion of  intake, ICANs/Screenings.  Communicate to Therapist Lead and Intake Coordinator if not completed in timely manner. 
• Add client demographics and client goals and update as needed to OnTarget system. 
• Identify and add authorizations for ICANs/Locus, OPT, CM, CS, PSR (update as needed). 
• Complete initial and updated Beacons 
• Identify if ICANS/LOCUS have been billed and billed on correct dates.  Will contact Lead Therapist if any issues. 
• Report critical concerns and problems to?Supervisor?in a timely manner and actively seek Supervisor’s?input and assistance to resolving the concern.?? 
• Reports to supervisor on a weekly basis. 

Consumer Charts: 

• Verify Medicaid approval on all potential consumers. 
• Requests support documentation from case workers, case manager, and therapist as needed  
• Print all forms (the corrected version) and provide to audit authorization for client’s chart.  
• Process generated extensions or denial letters 
• Participate in state and local audits. 

Professional Responsibilities: 

• Abide by and implement all the policies, procedures, regulations, and standards that govern the agency.  
• Represent Carolina Therapeutic Services Inc. professionally with all other agencies (i.e. schools, court system, mental health, department of social services, etc.) 
• Maintains strict confidentiality according to all Federal and State guidelines and requirements. 
• Upholds the Code of Ethics both professional and personally.  
• Maintains a cooperative relationship with all staff and others by demonstrating tact, courtesy, and a positive approach to communication. 
• Supports facility programs and activities. 
• Responsible for personal development to ensure current knowledge in the profession. 
• Responsible for maintaining a safe, clean and drug free environment. 

Communication: 

• Communicate pertinent Consumer and Stakeholder information to other employees/team members to insure quality of care. 
• Work with a team approach with other employees to ensure efficacy of care for ALL Consumers. 
• Follow chain of command when encountering problems or other areas of need and correct problems requested. 
• Solicit and cooperate with assistance of all support staff. 
• Actively participate in an appropriate manner with the decision-making process as “pro-active” team member and cooperate with team’s decision, whether programmatic or clinical.  
• Provide coverage on-site or as assigned by the needs of the agency.  
• Attend staff meetings, planned in-service training and any other regular or assigned meetings. 
• Responsible for any equipment assigned in order to perform duties.  
• Facilitate flow of information, particularly as it affects the delivery of services to consumers. 
• Perform other required job duties that the supervisor and/or director require to maintain continuity of care for consumers and profitability for the agency. 

Hours of Work:  

There is no “shift rotation” as such, however due the specialized nature of position; it is expected, that the employee will work the hours needed for client services as determined by the supervisor, agency coordinator, treatment team, and Carolina Therapeutic Services Inc. It is likely that this will occur somewhat regularly. Assignments can occur on weekends and after hours. Due to this after hours work, weekend work can also be assigned as defined by the needs of the client population.  

• Self-monitor the use of own time and the time of co-workers if it affects this position in the areas of service delivery, work hours, schedule, breaks, lunches, etc. Report any needs in this area to the supervisor and/or “chain of command”. 
• Shift variance to meet the needs of the clients. 
• Respond to pages or after hour calls in accordance to procedures.  
• Ability to provide twenty-four coverage and on-call support as scheduled/needed.  
• Attend all meetings and functions as required. 

Qualifications and Education Requirements: 

• Must be at least 18 years of age, be able to read, write and effect both written and verbal communication successfully; 
• Understand and follow directions. 
• Possess no substantiated findings of abuse or neglect listed on Health Care Registry, and no criminal convictions.  
• Higher school diploma or its equivalent 

Work requirements and Certification/Licenses Requirements:  

• Orientation to CTS Inc.  
• Receive training in population served, and client’s rights/confidentiality.  
• Experience with HIPAA and System Of Care is required.  
• Participate in and successfully complete all required trainings. 
• The employee must become privileged/credentialed in delivery of services.  
• CPR/First Aid, Medication Administration and Preventive Disease will be required.  
• Demonstrate core skills and training to deliver services.  
• Must have adequate transportation to deliver services, maintain required level of vehicle insurance in order to deliver services necessary to participate in consumer activities, i.e. hiking, sporting, education, etc.  
• Criminal records check, finger printing, and HCPR check is a prerequisite for employment consideration.  
• Maintain a Valid Driver’s License or State Identification.