Behavioral Health UM Reviewer (Licensed)-Adult Team-Remote-NC

Partners Behavioral Health Management•Morganton, NC

6d•Remote

About The Position

This position will evaluate medical necessity, appropriateness and efficiency of the services requested for authorization against established criteria adopted by the LME/MCO. The primary purpose of this role is to respond to all requests for authorizations from the provider community with appropriate authorization decisions guided by medical necessity and clinical guidelines. Services are authorized based on individual need and standardized procedures. The reviewer will handle initial, concurrent, urgent, and retrospective requests, consult with providers regarding these requests, and consult with Partners BHM physician regarding requests where authorization is questionable, or enrollee health and safety issues, medication issues, lack of response to services, and the need for Peer Review arise. Additionally, the role involves developing letters to communicate adverse decisions to enrollees and providers, including information on appeal options.

Requirements

Comprehensive knowledge of mental illness and appropriate treatment for major diagnostic categories.
Knowledge of behavioral health principles, techniques, and practices, and their application to complex treatment and service provision.
Considerable knowledge of person-centered and recovery philosophies and interventions.
Considerable knowledge of assessments and interventions for mental health, developmental disability, and substance use disorders.
Knowledge of the 1915 (b) (c) waiver.
Knowledge of psychiatric medications and side effects.
Knowledge of evidence-based practices.
Awareness of cultural diversity.
Excellent computer skills including proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.).
Ability to engage providers in collegial discussions about plans of care and best clinical practices for consumers.
Ability to establish and maintain effective working relationships with consumers and their families, as well as civic, legal, medical, social, and religious stakeholders.
Ability to express ideas clearly and concisely orally and in writing.
Ability to plan and execute work effectively and efficiently.
Ability to utilize complex telephone and computer systems, and to read and document information electronically.
Ability to make prompt decisions based on relevant facts.
Detail-oriented, able to independently organize multiple tasks and priorities.
Ability to effectively manage an assigned caseload under pressure of deadlines.
Must reside in North Carolina.
A Master’s Degree in a Human Services field with clinical licensure and two (2) years of post-Master’s experience in behavioral health; or a Registered Nurse with two (2) years of experience in behavioral health, post RN degree.
Current unrestricted license with the appropriate professional board of licensure in the state of North Carolina. Licensed to practice as a Registered Nurse in North Carolina by the N. C. Board of Nursing or Independent License in NC as a LCSW, LCMHC, LPA, LMFT. An Associate license does not meet the requirements.

Nice To Haves

An employee may be dual licensed with one of the specialties listed here can also be licensed as an LCAS. NC DMA contract requirements does not allow for an LCAS to be a standalone license for working in UM.

Responsibilities

Respond to all requests for authorizations from the provider community with appropriate authorization decisions guided by medical necessity and clinical guidelines.
Authorize services based on individual need and standardized procedures.
Review and authorize initial requests, concurrent requests, urgent requests, and retrospective requests.
Consult with providers regarding authorization requests.
Consult with Partners BHM physician regarding requests where authorization is questionable, enrollee health and safety issues, medication issues, lack of response to services, and need for Peer Review arise.
Develop letters communicating adverse decisions to enrollees and providers, including information on appeal options.