The Behavioral UM Clinician is responsible for conducting utilization and quality management activities in accordance with Utilization Management policies and procedures. The position responsibilities include the management of medical costs through timely prospective, concurrent and retrospective review activities.
Patient Relations, Care Management, Contributing to Team Success, Managing Work (including Time Management), Quality Orientation.
• Contributes to UM program goals and objectives in containing health care costs and maintaining a high quality medical delivery system through the program procedures for conducting UM activities;
• Performs telephonic review for inpatient and outpatient services using InterQual criteria or Health Integrated behavioral health criteria;
• Collects only pertinent clinical information and documents all UM review information using the software system;
• Promotes alternative care programs and researches available options including costs and appropriateness of patient placement in collaboration with health plan clients;
• Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services;
• Communicates with the designated medical director regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues;
• Recommends, coordinates and educates providers regarding alternative care options;
• Maintains an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital and health plan client discharge planners and social workers in the early identification of potential home care candidates or less restrictive level of care placement;
• Participates in UM program CQI activities;
• Communicates all UM review outcomes in accordance with the health plan client profile procedures;
• Follows relevant client time frame standards for conducting and communicating UM review determination;
• Maintains and submits reports and logs on review activities
• Identifies and communicates to the Director of Behavioral Utilization Management all hospital, ancillary provider, physician provider and physician office concerns and patient safety issues;
• Identifies and communicates to the Director of Behavioral Utilization Management supervisor all potential quality of care concerns;
• Serves as liaison for provider staff and the health plan client;
• Maintains courteous, professional attitude when working with all staff, hospital and physician providers, and health plan client;
• Identifies and communicates to health plan client and/or contracted ancillary providers all catastrophic and high risk cases for case management referral;
• Active participation in team meetings; and
• Performs other duties as requested by the Director of Behavioral Utilization Management or supervisor of Behavioral Health.
• Are readily available to answer questions of the non-clinical staff and shall ensure that non-clinical staff is performing within the scope of the non-clinical role.
• Offer input and assistance with development and delivery of orientation, education and training programs.
• Makes suggestions on program development to ensure effectiveness, quality, productivity, profitability and patient safety.
• Consults and seeks advise from licensed physician and/or medical director with expertise appropriate to the type of services being managed.
Customer Service Internal:
Supports a positive working environment;
Identifies and resolves potential personnel/peer problems and issues proactively, readily utilizing the Director of Behavior Utilization Management as a resource;
Communicates to Director of Behavioral Utilization Management all problems, issues and/or concerns as they arise;
Communicates to the Director of Behavioral Utilization Management any issues or concerns related to quality of care, using the Health Integrated procedure;
Maintains a courteous and professional attitude when working with all Health Integrated staff members and the management team; and
Actively participates in team meetings, as designated.
Customer Service External:
• Timely identifies and communicates to applicable practitioners, providers and the health purchaser staff all issues and concerns related to the case at hand;
• Communicates to the client/health plan staff any issues or concerns related to quality of care, using Health Integrated policies/procedures.
• Works, communicates and collaborates in harmony and in a courteous and professional manner with the patient, practitioner, provider and multidisciplinary health care team members all issues, concerns and/or as the UM Plan is revised and/or new services are implemented/terminated;
• Serves as a liaison and patient advocate when deemed applicable for quality of care and cost outcomes; and
• Communicates appropriately and according to policy, and/or regulatory requirements with the practitioner(s), provider(s), patient/patient’s legally appointed representative any UM coverage determination(s).
Strong communication, documentation, clinical and critical thinking skills essential; Working
knowledge of utilization management preferred; Strong problem solving and decision making skills
essential; Strong typing and computer skills essential.
Licensed healthcare professional (LCSW, LMHC, LMFT, RN, PsyD) with a currently active and unrestricted license to practice as a health professional in a state or territory of the United States required.
Work Experience Requirements:
One to two years of experience in utilization review, quality assurance, discharge planning or other cost management programs and/or a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review preferred. One to two years directly related experience using InterQual criteria or healthcare criteria preferred. Minimum of three (3) years of clinical experience with direct client care in a behavioral health setting required. Behavioral health experience in multiple levels of care for Behavioral Health Utilization Management preferred. Experience with Austin Spectrum Disorder and developmental disorder related population care/coordination needs (i.e ABA). Familiarity with call center type of environment and expectations are desirable.