•Work telephonically with patients identified as high risk to identify needs, set goals and implement action steps towards achieving goals. Empower patients to help them improve their quality of life.
•Comply with established referral, pre-certification and authorization policies, procedures and processes by related Medical Management staff.
•Participate in on-going communication between case management staff, utilization management staff, health plan partners and contracted providers.
•Assist with the implementation of policies and procedures regarding case management and utilization management functions.
•Maintain compliance with federal and state regulations and contractual agreements.
•Coordinate case management functions with other departmental functions as assigned.
•Monitor the effectiveness of existing procedures and outreach/intervention efforts.
•Conduct appropriate knowledge/education and interventions for members defined to be at risk.
•Monitor data to address trends or potential quality improvement opportunities including provider issues, service gaps, member needs.
•Maintain HIPAA compliance. Field position- up to 65% travel.
Master's degree in Behavioral Health. LCSW, LMFT, LPC, PhD, PsyD or RN license. 3+ years of case and/or utilization management experience. Experience in psychiatric and medical health care settings. Working knowledge of utilization review procedures, and familiarity with mental health community resources. Thorough knowledge of a specialized or technical field such as clinical nursing, case and/or utilization management involving knowledge plus the application of basic theory. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.
License/Certification: Unrestricted license as a LCSW, LMFT, LPC, PhD, PsyD or RN.