Behavioral Health Utilization Management Clinical Coordinator

UnitedHealth Group • Grand Junction, CO

80d • $28 - $50 • Remote

About The Position

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. The Clinical Coordinator is responsible for processing all Behavioral Health and Substance Use Disorder authorizations within designated turnaround times for various lines of business, including RMHP DSNP, RMHP Medicare, RMHP PRIME Medicaid, RMHP RAE Medicaid, RMHP CHP+, RMHP IFP, and NHP RAE Medicaid. This role involves applying approved medical necessity criteria, escalating cases to secondary medical director review when necessary, and collaborating with leadership and medical directors on complex cases. The Clinical Coordinator proactively manages and identifies potential barriers for members, ensuring they receive necessary care and support. They refer members to the RMHP Care Coordination Department for specific needs, notify providers and requestors of authorization determinations, and offer peer-to-peer consultations when cases do not meet criteria. Additionally, the Clinical Coordinators draft denial letters, validate eligibility, input authorization requests into electronic health records, and provide assistance to callers. They complete required trainings, participate in annual Inter-Rater Reliability testing, and facilitate care coordination meetings. The role also involves engaging members in the RMHP Contingency Management Program, collaborating with facility staff, providing consultations, maintaining confidentiality, supporting evidence-based practices, establishing and maintaining professional relationships, identifying the need for higher-level reviews, formulating case overviews, administering benefits, handling escalated calls, and applying clinical knowledge to determine medical appropriateness.

Requirements

• Current, unrestricted independent licensure as a LAC, LPC, LMFT, LCSW in Colorado.
• 4+ years directly serving individuals with behavioral health conditions (mental health/substance use disorders).
• 1+ years of experience with local behavioral health providers and community support organizations addressing SDoH.
• 1+ years of experience with MS Office, including Word, Excel, and Outlook.
• Substance use treatment experience and/or behavioral health treatment experience.
• Ability to work Monday - Friday, 930am-6pm Mountain Standard Time.

Nice To Haves

• Utilization Management experience.

Responsibilities

• Process all Behavioral Health and Substance Use Disorder authorizations submitted by providers within the designated turnaround times specified in the Prior Authorization List for all lines of business.
• Apply approved medical necessity criteria and appropriately escalate cases to secondary medical director review when necessary.
• Collaborate with leadership to discuss authorization requests when additional guidance is required.
• Proactively manage and identify potential barriers for members, activating appropriate entities and departments to ensure members receive the necessary care and support.
• Collaborate with the medical director on complex cases to ensure members receive appropriate treatment.
• Refer members to the RMHP Care Coordination Department when specific needs are identified.
• Notify providers and requestors of all authorization determinations.
• Offer peer-to-peer consultation with the RMHP medical director when a case does not meet criteria.
• Draft denial letters informing members and providers of decisions and reasons for those decisions.
• Verify eligibility of providers and members for all authorization requests.
• Input authorization requests into an electronic health record.
• Provide assistance to callers routed to the BH UM department.
• Complete required trainings by the assigned due dates to comply with auditing entities such as NCQA.
• Participate in annual Inter-Rater Reliability testing and pass with a score of 90% or higher.
• Attempt to obtain missing information from requestors for incomplete authorization requests.
• Schedule and facilitate care coordination meetings with members receiving substance use disorder residential treatment.
• Engage members in the RMHP Contingency Management Program by submitting referrals to Care Management staff.
• Collaborate with facility staff, attend meetings, and address provider concerns.
• Provide consultation to providers and/or consumers on various issues including benefit information and coverage determinations.
• Maintain confidentiality as described in the UHG Employee Handbook.
• Support outcome-focused, evidence-based best practices and guidelines with providers.
• Establish and maintain professional working relationships with referral sources, community resources, and care providers.
• Identify and communicate network gaps in care to Leadership.
• Document concise case reviews.
• Manage member benefits, review treatment plans, and coordinate transitions between various levels of care.
• Address escalated calls to resolve complex issues.
• Apply clinical knowledge and critical thinking to evidence-based guidelines.
• Send correspondence to practitioners, providers, and members regarding authorization status/updates.
• Maintain job aids for team operations current and updated as needed.

Benefits

• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase.
• 401k contribution.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: Master's degree