Utilization Management Specialist

Utilization Management Specialist

(Care Management Specialist)

PAY GRADE: $69,328.99 - $86,426.61 Annually
$6,000 Recruitment Bonus for Clinical Master level new hires!! ($2,000 paid at start, $2,000 paid after 3 months, and $2,000 paid after successful probation period.)

Are you a limited or fully licensed social worker, professional counselor, therapist, or psychologist looking for an administrative position while still utilizing your clinical skills? If so, look no further! This position is for you!!

POSITION SUMMARY:

Under supervision of the Manager of Utilization and Care Authorization, monitors appropriate uses of Saginaw County Community Mental Health Authority (SCCMHA) resources for treatment and support of individual episodes of care, coordination of care and adequacy of supports and services to sustain outcomes. This position uses best practice that are derived from scientific evidence to bring together Behavioral Healthcare (BH) and Substance Use Disorder (SUD) resources from across the continuum of care in the most appropriate, effective, and efficient manner to the consumer specific duties within utilization review. Utilization review may be assigned within individual staff scope of practice and target population expertise. Providing overall coordination of behavioral healthcare and/or substance use disorder planning, service delivery leadership, and integration facilitation throughout the SCCMHA network (including assessment, person centered planning, prevention, treatment, and recovery as it relates to MI CMS Certified Community Behavioral Health Center (CCBHC) Demonstration handbook. Ensures that SCCMHA meets compliance obligations in all BH and SUD areas. Provides key local community, regional PIHP, and State linkages as appropriate for the scope of BH and SUD programs and policies for SCCMHA, including reporting, ongoing education/training, development, and evaluation purposes. Performs responsibilities and tasks with a demeanor and attitude that promotes goodwill, builds positive relationships, communicates respect for human dignity and contributes positively to the mission and values of SCCMHA. This position will be knowledgeable about and actively support culturally competent recovery-based practices; person centered planning as a shared decision-making process with the individual, who defines his/her life goals and is assisted in developing a unique path toward those goals; and a trauma informed culture of safety to aid consumer in the recovery process.

ESSENTIAL DUTIES AND RESPONSIBLITIES:

1. Provides preauthorization of services based on review of assessments and the medical record for evidence of medical necessity and within the definition of the benefit. Acts on behalf of the client to assure that necessary clinical services are received, and that progress is being made.

2. Works closely with the Central Access and Intake unit to facilitate eligibility assessment, referral options, and primary team assignment for new consumers.

3. Reviews level of functioning assessments including CAFAS, LOCUS, PECFAS, ASAM and others as implemented by SCCMHA and decides on appropriate level of care placement BH and SUD treatment services.

4. Manages a large utilization review caseload for service authorization requests received from multiple assigned primary teams with annual rotation of teams’ assignments by Manager of Utilization and Care Authorization.

5. Manages as assigned primary record holder a small outgoing County of Financial Responsibility (COFR) service delivery caseload for consumers who reside outside of Saginaw County.

6. Works in multiple electronic health record systems with the ability to ensure data integrity and accurate data interface between systems.

7. Provides concurrent review of community-based services and works as a team member with utilization management tasks related to management of the benefit. These services include, but are not limited to, assessment, care planning, education, referral, advocacy, monitoring, and periodic reassessment. Episodes of care may be selected for sample review or flagged for review due to under or over utilization or due to inadequate documentation in the person-centered plan and supporting assessments. Concurrent review of services includes review of assessment and plan for concurrence with Protocols, consultation with primary care provider and/or consumer, and may include written recommendations to the provider and consumer incorporating suggestions for modifications to the consumer's plan.

8. Through concurrent review and provider profile review, may recommend based on care management performance indicators, the denial of authorization or reauthorization of service or may suggest reduction in the quantity or duration of services. If reduction or denial of service is recommended, will prepare and/or present the proposed reduction or denial in the multidisciplinary Care Conference Review Committee. If denial or reduction of service is supported in conference, will ensure due process of Adequate or Advanced notice to the consumer/guardian.

9. Prepare written justification of denial with suggestions for alternative resources when denying services through preauthorization review or concurrent utilization review documentation.

10. May issue recommendation for provider restitution of payments if documentation of eligibility is not complete or adequate to support eligibility certification in the medical record.

11. Prepares individual utilization profile analysis reports and makes recommendations for primary care providers. Profile preparation includes data analysis, record review and written analysis and recommendations.

12. Conduct provider training in Care Management Policies and procedures, , eligibility assessment criteria, severity of illness/intensity of service requirements, coordination of care standards, service protocols and utilization management performance indicators. Training may also be provided to other groups including Citizens Advisory Committee, community groups and others as requested by the Chief of Network Business Operations. The role of these trainings will be to reduce the incidence of denial or reduction of service decisions.

13. May recommend SUD integration policy, practice or procedural changes or new practices for SCCMHA consideration.

14. Participates in process improvement committees as assigned, including preparation of summaries of findings for review by supervisory staff.

15. Is responsible for accurate and timely codification and entry of data and writing of reports, communication of decisions to providers and consumers.

16. Serves as population expert for all BH and SUD services, programs, providers, and requirements.

17. Represents SCCMHA in treatment and prevention settings.

18. Provides leadership coordination and consultation within the SCCMHA network and community for BH and SUD services.

19. Promotes service integration for persons with SUD disorders within mental health systems, including primary care providers.

WORKING CONDITIONS/ENVIRONMENT:

Works in an office environment with normal time constraints and pressures. Uses a workstation, keyboard and views a computer screen for long periods, uses telephone and headset. May involve travel to multiple service locations.

QUALIFICATIONS:

Education: Master’s degree in a mental health related field from an accredited school required.

Experience: A minimum of five (5) years progressive experience in preferably diverse treatment settings including: psychiatric inpatient, SUD outpatient, managed care, and case management. Consideration of experience and scope of practice will be uniquely considered for each team vacancy as the agency requires a team which enables us to manage a wide range of special needs populations (developmental disabilities, substance use disorder, VA, children, mentally ill and medical health specifically in a hospital setting and/or medical clinic.) and determined in interviews, with depth and range given more preference.

Licenses and Certifications: Valid Michigan Driver’s license with a good driving record.

Must be able to apply and obtain a limited licensed master’s social worker (LLMSW), licensed master’s social worker (LMSW), limited licensed professional counselor (LLPC), licensed professional counselor (LPC), limited licensed marriage and family therapist (LLMFT), licensed marriage and family therapist (LMFT), limited licensed psychologist (LLP) and licensed psychologist (LP). Must have or obtain a certification in substance use treatment specialist area. CADC, CAADC

Knowledge, Skills, and Abilities:

1. Demonstrated competency in scope of practice as social worker, Substance Use Counselor.

2. Possess knowledge of BH and SUD benefits.

3. Professional level verbal and written communication skills.

4. Ability to produce accurate and comprehensive work products with minimal direction.

5. Ability to exercise mature judgment and maintain strict confidentiality.

6. Ability to maintain favorable interpersonal working relationships and positive public relations.

7. Ability to plan and organize work, perform tasks consistently and adhere to priorities.

8. Ability to provide small group leadership.

9. Ability to assess and diagnosis chemical dependency. Knowledge of chemical dependency, ASAM and mental health best practice.

10. Problem solving and mediation abilities.

(Listed qualifications are for guidance in filling this position. Any combination of education and experience that provides the necessary knowledge, skills, and abilities will be considered; however, mandatory licensing or certification requirements cannot be waived. Physical/mental requirements cannot be waived unless specifically indicated.)

Full Job Description Attached