Access & Utilization Manager - Social Services

Four Oaks Family & Children Services•Cedar Rapids, IA

About The Position

At Four Oaks, we believe that every child needs the opportunity to succeed. It’s more than our mission – it’s the passion that permeates everything we do. Four Oaks has grown to become one of the state’s largest agencies devoted to child welfare, education, juvenile justice and behavioral health. We recognize that children and families come to us from a variety of circumstances, which makes it important for us to reach kids and families where they are right now. For that reason, we provide prevention, intervention and treatment programs and services. As the Access &Utilization Manager you will be responsible for ensuring member access to timely and appropriate services funded by Medicaid Managed Care Organizations (MCOs) and private insurance. This position provides quality customer care services for both internal and external customers, completes timely documentation and oversees responsible work performance expectations established by the organization. Specific responsibilities include: Assess clinical information at the time of referral and intake (initial authorizations) anf reauthorization and transition/discharge planning to promote appropriate use of resources & quality care. Check Medicaid eligibility on all clients prior to admit, as well as twice monthly, or at the time of funder change, as needed. Identify and secure prior approval funding from any/all funders such as MCO, private insurances or private pay (as well as identify any co-pays). Enter all funding accurately into Visionworks and notifies Utilization Management (UM) Director immediately on any funding denials. Maintain appropriate documentation, following UM and contract standard operating procedures. Provide assistance, approval, and intervention with program staff as needed to determine medical and psychological necessity, appropriateness of care, and extended length of stay or other preauthorization decisions. Consult with program staff on an ongoing basis to improve collaborative decision-making, review clinical guidelines, monitor clinical issues and trends across behavioral health services provided under contract with MCOs. Collaborate with the Effectiveness Team to identify and implement quality initiatives to improve member health outcomes through more effective UM concurrent and retrospective review processes. Request, track, and monitor PMIC clients needing a Single Case Agreement level of funding. Track and report on UM performance metrics, including monitoring and tracking metrics to identify patterns of utilization, such as over-utilization, under-utilization, and inefficient scheduling of resources. Monitor potential high-cost rates, readmissions, and other UM statistics such as readmissions within 30 days of discharge; partner with the Effectiveness Team to develop and implement action plans for approval as needed. Uplift high risk cases to Director and supervisors/administrative staff. Consult with Director and/or designated Program Staff as needed to troubleshoot difficult or complex cases, resolving identified problems in a timely manner. Promote effective partnerships with referral sources, Members, MCOs, Insurance companies and other referring agencies. Participate in required audits and comply with all reporting requirements. Follow the standards set forth in the internal and external manuals appropriate to the contract(s). Coordinate interdisciplinary treatment in line with authorized purchased services. Facilitate community resources planning, case progress evaluations, permanency and crisis planning. Participate in discharge planning and documentation. Interfaces with school, medical/nursing, psychiatric contact, referring workers, and collaterals.

Requirements

You will need an Associate’s degree and 2 years of related experience or a Bachelor’s degree and 1 year of related experience for this position.
Experience with billing and handling claims (submitting, tracking, and following up).
Comfortable working through claim issues and making sure things are accurate and completed on time.
Effective verbal and written communication skills
Strong analytical and problem solving abilities
Basic to intermediate computer skills in a MS Office environment
Ability to maintain a flexible work schedule

Responsibilities

Assess clinical information at the time of referral and intake (initial authorizations) anf reauthorization and transition/discharge planning to promote appropriate use of resources & quality care.
Check Medicaid eligibility on all clients prior to admit, as well as twice monthly, or at the time of funder change, as needed.
Identify and secure prior approval funding from any/all funders such as MCO, private insurances or private pay (as well as identify any co-pays).
Enter all funding accurately into Visionworks and notifies Utilization Management (UM) Director immediately on any funding denials.
Maintain appropriate documentation, following UM and contract standard operating procedures.
Provide assistance, approval, and intervention with program staff as needed to determine medical and psychological necessity, appropriateness of care, and extended length of stay or other preauthorization decisions.
Consult with program staff on an ongoing basis to improve collaborative decision-making, review clinical guidelines, monitor clinical issues and trends across behavioral health services provided under contract with MCOs.
Collaborate with the Effectiveness Team to identify and implement quality initiatives to improve member health outcomes through more effective UM concurrent and retrospective review processes.
Request, track, and monitor PMIC clients needing a Single Case Agreement level of funding.
Track and report on UM performance metrics, including monitoring and tracking metrics to identify patterns of utilization, such as over-utilization, under-utilization, and inefficient scheduling of resources.
Monitor potential high-cost rates, readmissions, and other UM statistics such as readmissions within 30 days of discharge; partner with the Effectiveness Team to develop and implement action plans for approval as needed.
Uplift high risk cases to Director and supervisors/administrative staff.
Consult with Director and/or designated Program Staff as needed to troubleshoot difficult or complex cases, resolving identified problems in a timely manner.
Promote effective partnerships with referral sources, Members, MCOs, Insurance companies and other referring agencies.
Participate in required audits and comply with all reporting requirements.
Follow the standards set forth in the internal and external manuals appropriate to the contract(s).
Coordinate interdisciplinary treatment in line with authorized purchased services.
Facilitate community resources planning, case progress evaluations, permanency and crisis planning.
Participate in discharge planning and documentation.
Interfaces with school, medical/nursing, psychiatric contact, referring workers, and collaterals.