Job Summary
Ensure consistent application and management of Kaiser Permanente mental health and chemical dependency benefits.
Essential Responsibilities
Benefit payment authorizations: Manage behavioral health benefits by providing medical necessity determinations. Determinations are completed by gathering the most current clinical information from the assessing/treating provider and applying the approved Kaiser Permanente medical necessity criteria to determine what can be authorized within the benefit provisions. Criteria are used for all pre‑authorization, concurrent review, and post‑service requests. Authorizations must be for the most clinically appropriate, least restrictive, most cost‑effective approach within standards of care to safely treat the member.
Member contact: Provide member contact for a variety of reasons, including benefit explanations, resource identification, and appointment scheduling.
Payment denials: Follow Kaiser policies for all benefit payment denials. The UM coordinator is always available to explain a payment denial to providers and members.
Consultations: Provide consultations to internal and external providers regarding medical necessity interpretation, benefits, covered services, contracted providers, and available resources that meet the clinical needs of the Kaiser member.
Fraud and abuse: Ensure appropriate expenditure of healthcare dollars in accordance with rules and regulations set forth in Kaiser policies, licensing and credentialing entities, and all state and federal laws and regulations.
Continuity of care: Facilitate communication between service providers regarding treatment planning, intervention, outcomes, and recommendations.
Care coordination: Ensure that upon discharge from higher levels of care all members have an appropriate discharge plan within HEIDIS guidelines.
On‑call rotation: Participate in the on‑call rotation as assigned to cover pre‑authorizations for non‑business hours.
Basic Qualifications
Minimum three (3) years of experience working directly or indirectly with individuals with mental health or chemical dependency conditions, including diagnosing, treating, or managing.
Minimum two (2) years of experience in utilization management and discharge planning.
Education
Master’s degree in mental health, social work, or a closely related field from an accredited institution.
Additional Requirements
Understanding of medical necessity criteria and its application.
Knowledge of DSM‑IV diagnoses, community standards of treatment, and treatment interventions for mental health, addictions, and co‑occurring disorders.
Familiarity with community resources.
Knowledge of how behavioral health benefits work.
Good clinical judgment in assessing the clinical needs of patients and matching those needs to the appropriate level of care.
Demonstrated ability to develop successful interpersonal relationships and earn the respect of physicians, nurses, therapists, and other personnel.
Able to participate as a team member, yet demonstrates high level of self‑motivation and ability to work independently.
Excellent oral and written communication skills.
Excellent problem‑solving abilities, detail oriented, and very organized.
Use medical criteria for UM decision‑making and education with patients, providers, and community providers.
Ability to effectively utilize computerized medical records, Microsoft Office software, and analytical software.
Ability to collect, analyze, and report statistically meaningful quality and utilization data.
Excellent written and verbal communication skills; presentation skills; analytical problem‑solving skills; well‑developed project management skills; and competent quantitative skills.
Preferred Qualifications
Minimum five (5) years of experience working directly or indirectly with individuals with mental health or chemical dependency conditions, including diagnosing, treating, or managing.
Current, unrestricted license/certificate in the state where the job is assigned (e.g., Oregon LCSW, LMFT, LPC, Psychologist, CADC; Washington LICSW, LASW, LMFT, LMHC, Psychologist, CDP).
Understanding of Milliman Criteria, ASAM Criteria, and both Kaiser and community UM processes and procedures.
Knowledge of Kaiser Permanente resources, Behavioral Health system, and benefits.
Understanding of insurance operations and applying benefits.
Ability to apply medical necessity criteria solely on clinical relevance without basing decisions on financial outcomes.
Demonstrated ability to work with providers within contractual relationships and develop positive working relationships.
Ability to issue and explain adverse benefit determinations.
Seniority level
Mid‑Senior level
Employment type
Full‑time
Job function
Health Care Provider
Industries
Hospitals and Health Care
Location: Portland, OR
Salary: $62,700 – $65,000 per year
Posted: 1 week ago