UTILIZATION MANAGEMENT CLINICIAN - BEHAVIORAL

REPORTS TO: Director of Utilization Management
SUPERVISES: None

JOB SUMMARY: The Utilization Management Nurse 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.

MINIMUM QUALIFICATIONS:

Education: Registered Nurse, LCSW, LMHC, LMFT, PhD., or PsyD., with an unrestricted license.  Upon hire or transfer clinician will be expected to obtain licensure in states where Health Integrated conducts business.  BSN preferred. 
Experience:

One to two years of experience in utilization review, quality assurance, discharge planning or other cost management programs preferred.  One to two years directly related experience using InterQual criteria or healthcare criteria preferred.  Two (2) years experience in hospital-based nursing required.  Medical-surgical care experience preferred for positions in medical management areas.  Behavioral health experience in multiple levels of care for Behavioral Health Utilization Management preferred.
Knowledge/skills:

Strong communication, documentation, clinical and critical thinking skills essential; Working knowledge of utilization management/case management preferred; Strong problem solving and decision making skills essential;  Strong typing and computer skills essential.

ACCOUNTABILITIES:

Overall Job Performance/Responsibilities:

  • 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 CMS 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 directly 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;
  • Call center knowledge desirable
  • 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 as outlined by the UM program operational procedures;
  • Identifies and communicates to the Director of Utilization Management all hospital, ancillary provider, physician provider and physician office concerns and issues;
  • Identifies and communicates to the Director of 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 CMS HealthCare 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 Utilization Management.

Customer Services-Internal:

  • Supports a positive working environment;
  • Identifies and resolves potential personnel/peer problems and issues proactively, readily utilizing the Utilization Management Supervisor as a resource;
  • Communicates to Director Utilization Management all problems, issues and/or concerns as they arise;
  • Communicates to the Director of 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 Services-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).

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