Behavioral Health Utilization Manager
About The Position
The Behavioral Health Utilization Manager reviews and authorizes behavioral health and substance abuse services across inpatient, residential, and outpatient settings, applying approved medical-necessity criteria and health plan requirements. The role manages members’ utilization of resources and progress through care, monitors treatment for appropriateness and effectiveness, supports care planning and discharge planning, and may conduct prior authorization, concurrent, retrospective, and appeal reviews. It provides telephonic or electronic document review and collaborates with members, providers, medical directors, and interdisciplinary teams to support appropriate and timely care decisions. The position also identifies quality-of-care concerns and barriers to effective service delivery, and may educate others and recommend alternative care plans within the scope of the employee’s position and licensure. The position supports process-improvement initiatives and population-level outcomes, communicates information needed for utilization and regulatory requirements, and educates internal team members on case management and managed care concepts. It is entirely remote and requires Arizona residency for compliance. The regular schedule is Monday through Friday, primarily 8:00 a.m. to 5:00 p.m. Arizona time. There are no direct or indirect supervisory responsibilities.
Requirements
- Master’s degree in social work, counseling, or a related field, or an applicable degree with independent or associate licensure.
- Licensure in a state-law-required category of social work, professional counseling, or marriage and family therapy; listed applicable licenses include LCSW, LMSW, LPC, LAC, or Licensed Psychologist.
- Three years of clinical experience, such as counseling, care management, case management, or care coordination in inpatient or outpatient settings.
- Working knowledge of care management, case management, and hospital and community resources.
- Critical-thinking and problem-solving skills.
- Effective communication and time-management skills.
- Ability to work effectively independently and as part of an interdisciplinary team.
- Arizona residency for compliance.
Nice To Haves
- Previous experience with behavioral health utilization management.
- Additional related education and/or experience.
Responsibilities
- Manage individual members across the health care continuum to achieve optimal clinical, financial, operational, and satisfaction outcomes.
- Participate in process-improvement activities for patient populations.
- Evaluate the medical necessity and appropriateness of care.
- Build collaborative relationships with physicians, other payers, and health care team members; collect and communicate pertinent information to meet utilization and regulatory requirements.
- Collaboratively develop and manage interdisciplinary patient discharge plans and communicate them across the continuum of care.
- Educate internal health care team members on case management and managed care concepts and facilitate their integration into daily practice.
- Review and authorize behavioral health and substance abuse services in inpatient, residential, and outpatient settings using approved medical-necessity criteria.
- Monitor care to ensure treatment is appropriate and effective; assess members’ plans of care and document resource utilization and progress.
- Engage internal and external resources to support appropriate care planning and discharge planning.
- Monitor for quality-of-care concerns and identify or resolve barriers that may hinder effective care delivery.
- Staff regularly with medical directors.
- Within the scope of position and licensure, provide education and recommend alternative care plans when treatment does not meet medical-necessity criteria.
- May conduct prior authorization, concurrent, retrospective, and appeal reviews.
- Perform duties according to established policies, procedures, regulatory and accreditation requirements, and applicable professional standards.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
