Behavioral Health UM Reviewer (Licensed)-Remote-NC

Partners Behavioral Health Management • Morganton, NC

7d • 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 role involves responding to authorization requests from the provider community, authorizing services based on individual need and standardized procedures, and reviewing initial, concurrent, urgent, and retrospective requests. The position also includes consulting with providers and the Partners BHM physician regarding authorization requests, enrollee health and safety issues, medication issues, lack of response to services, and the need for Peer Review when requests cannot be approved. Additionally, the role involves developing letters to communicate adverse decisions to enrollees and providers, along with information on appeal options.

Requirements

• 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.
• Must reside in North Carolina.
• 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.
• Comprehensive knowledge of mental illness and appropriate treatment for major diagnostic categories; 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 consumer
• 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, and 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, and to effectively manage an assigned caseload under pressure of deadlines

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 decision that is 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 in which there is a question regarding authorization, enrollee health and safety issues, medication issues, lack of response to services and need for Peer Review when the MHSU Utilization Management Reviewer cannot approve the request for treatment
• Develop letters that communicate to enrollees and providers the reason for any adverse decision and offers information regarding the options to appeal any adverse decision

Benefits

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs
• Public Service Loan Forgiveness Qualifying Employer

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level