Overview The Behavioral Health Utilization Management (BH UM) Clinician is responsible for conducting utilization and quality management activities in accordance with New York State and MetroPlusHealth Utilization Management policies and procedures. The position manages medical costs through timely prospective, concurrent, and retrospective review activities.
Base pay range
$86,500.00/yr - $86,500.00/yr
Work location and schedule Work Shifts: 9:00AM-5:00PM
Responsibilities Performs telephonic review for inpatient and outpatient services using InterQual with Secondary Dimensions & LOCADTR and OMH Criteria Sets
Contributes to UM program goals and objectives in containing health care costs and maintains a high-quality medical delivery system through departmental UM procedures
Collects all pertinent clinical information and documents within CareConnect
Promotes alternative care programs and researches available options including costs and appropriateness of patient placement in collaboration with health plan members
Communicates directly with Physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services
Communicates with 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
Educates providers on medication and treatment compliance while also promoting the use of Long Acting Injectables
Enlists existing provider network in promoting first episode psychosis treatment
Educates providers to alternate treatment services being promoted by Health + Hospitals in lieu of Inpatient Detox
Attends and prepares for bi-Weekly Interdisciplinary Care Team (ICT) meetings with newly enrolled, frequently admitted, high utilizing at-risk CORE and HARP members
Evaluates housing needs and collaborates timely with MetroPlusHealth internal housing team for supportive assistance
Maintains an active role in assuring continuity of care for all inpatients through early discharge planning and collaboration with hospital discharge planning staff
Identifies potentially catastrophic and high-risk cases for case management referral
Identifies and communicates potential quality of care concerns to the BH UM Clinician Team Lead in a timely manner
Contributes to MetroPlusHealth corporate goals through ongoing active team participation and participation in education and trainings
Performs other appropriate UM Behavioral Health duties and participates in special projects as assigned, including monthly audit review and preparation, quality improvement, community health education, facility/provider relations and marketing activities
Support coverage for Retrospective Reviews and BH UM Appeals as needed
Qualifications Master’s Degree required
Minimum 3 years of Behavioral Health (Serious Mental Illness & Substance Use Disorder) experience in managed care utilization review, quality assurance, discharge planning (experience in a Psychiatric Hospital Inpatient and/or Outpatient setting preferred)
Previous experience within the Integrated Collaborative Care Model Approach
Experience with chronic condition management, particularly Diabetes, HIV, Heart Disease
Pharmacy, LOCADTR, InterQual, Guiding Principles, MAPP, etc. knowledge
Medical background and bilingual preferred
Previous Quality Management liaison experience with hospitals and other large volume providers to address cost and HEDIS/QARR quality performance, preferred
Licensure And/or Certification LCSW, LMSW, or LMHC. Current valid unrestricted NY State License.
Professional Competencies Integrity and Trust
Teamwork and Problem-Solving Attitude
Customer Service
Superior Technical Computer skills (Microsoft Office, Care Connect, Teams)
Exceptional Organizational and Communication Skills
Strong interpersonal and assessment skills suitable for challenging providers
Seniority level Mid-Senior level
Employment type Full-time
Job function Health Care Provider
Industries Hospitals and Health Care