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Utilization Review - Behavioral Health

Bedford, NH · Healthcare
About the Company: 
A Fortune 500 company, is a diversified, multi-national healthcare enterprise that provides a portfolio of services to government sponsored healthcare programs, focusing on underinsured and uninsured individuals.  Many receive benefits provided under Medicaid, including the State Children's Health Insurance Program (CHIP), as well as Aged, Blind or Disabled (ABD), Foster Care and Long Term Care (LTC), in addition to other state-sponsored/hybrid programs, and Medicare (Special Needs Plans).  

The Company operates local health plans and offers a range of health insurance solutions.  It also contracts with other healthcare and commercial organizations to provide specialty services including behavioral health management, care management software, correctional healthcare services, dental benefits management, in-home health services, life and health management, managed vision, pharmacy benefits management, specialty pharmacy and telehealth services.


Position Overview:
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.

Responsibilities:
  • 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.

Qualifications:
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.
  • Advanced organization and communication skills are highly preferred.
  • Intermediate to advanced computer skills are highly preferred.
     
License/Certification:
  • Required to have license to practice independently, and/or have obtained the state required licensure as outlined by the applicable state.
  • This includes but is not limited to licenses such as LPC, LCSW, LMFT, LMHC, LIMHP, and RN.

 
Benefits: 
  • The company offers more than just medical insurance. They pay most of your benefits costs and in some cases – they pay 100 percent. Most of the benefits not covered by the company are paid with pre-tax payroll deductions. 
  • Health insurance
  • Dental insurance
  • Vision insurance
  • Flexible spending accounts (includes health care, dependent care mass transit reimbursement)
  • Short- and long-term disability insurance
  • Basic Life insurance
  • Supplemental AD&D
  • Supplemental life insurance
  • Wellness Program
  • 401(k) retirement with company match
  • Employee stock purchase plan
  • Vacation, Personal and Sick time
  • Paid Company Holidays
  • Employee Assistance Program (EAP)
  • Training and Learning Opportunities
  • Tuition Reimbursement/Educational Assistance
  • Service Awards
  • On-site fitness center or discount at local fitness centers (most locations)
  • Discounts for select local and national products and services, including cell phones, computers and more
  • Other amenities may be available, but vary by location
 
Kat Forester
ProEnlist, LLC

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