UM Clinical Specialist-Behavioral Health (Full Time, Remote, North Carolina Based)

Alliance Health•Durham, NC

12h•$69,592 - $88,729•Remote

About The Position

The UM Clinical Specialist-Behavioral Health performs professional and administrative work, primarily utilization reviews, utilization management, and active care management to support economical and effective consumer service delivery by PHIP-enrolled network providers. The position reviews individualized service plans and requests for authorization to determine medical necessity and help ensure consumers receive services in the least restrictive, most integrated setting appropriate to their needs. The primary focus is services under the Medicaid B waiver and state-funded benefits, along with related work. The work schedule is primarily remote, with no routine office attendance expected. The employee may be required to attend business and team meetings at the Alliance Office as needed. The role includes clinical review, care management, monitoring treatment plans and utilization, supporting access to appropriate treatment, notifying members of adverse benefit determinations while preserving due process rights, documenting decisions, and maintaining professional licensure and knowledge of best practices for individuals with MH/SUD/IDD.

Requirements

Master’s degree in a Human Services field, such as Psychology, Social Work, or Counseling, and at least five years of post-degree clinical experience providing similar services to the population served (MH/SUD); OR a master’s degree in Psychiatric Nursing and five years of relevant psychiatric nursing experience; OR a Bachelor of Science in Nursing and five years of relevant psychiatric nursing experience.
Current and active license issued by a North Carolina Professional Board, such as LCSW, LCAS, LP, LPA, LMFT, LCMHC, or RN.
Considerable knowledge of case management principles, practices, and applications.
Considerable knowledge of agency and community programs and services affecting clients and applicants.
Knowledge of state and federal client-rights protection statutes and regulations, applicable laws and regulations, including URAC, applicable Code of Federal Regulations, and NC Administrative Code.
Effective written and oral communication, interpersonal, and presentation skills.
Ability to identify rights-protection complaint issues; set, monitor, and evaluate quality standards; and assess plans for meeting individual client needs.
Considerable knowledge of DSM-5-TR diagnostic criteria.
Ability to manage time, prioritize work, and use problem-solving approaches.
Ability to coordinate effectively with staff from various agencies and interdepartmentally.
Ability to read, analyze, and interpret regulations, policies, and procedures.
Ability to coordinate work with a variety of individuals and agencies.
Ability to operate computer equipment and generate reports and records, and to express ideas clearly and concisely in oral communication and written documents.
Proficiency in Microsoft Office products such as Word, Excel, and Outlook.

Nice To Haves

Experience in the public behavioral healthcare field is highly desired because of the complexity of the work.
Experience in a behavioral healthcare utilization management environment is valuable.

Responsibilities

Independently review service requests submitted by providers for medical necessity against clinical guidelines and within contractually mandated turnaround times.
Conduct utilization reviews to monitor adherence to clinical practice guidelines and best-practice standards and determine whether services were delivered as requested.
Engage in care management, including consumer and provider follow-up calls and case staffing with psychologists and medical staff, to support appropriate treatment referrals.
Monitor consumer person-centered plans and consult with treating providers about adjustments needed to meet consumer needs.
Monitor and report consumer- and provider-specific over- and under-utilization.
Identify high-risk consumers and individuals with special health care needs for referral to Care Coordination and case escalation.
Provide linkage, authorizations, and level-of-care determinations, and assist providers and Care Coordinators with alternative approaches to care.
Ensure compliance with care management and quality improvement policies and procedures, utilization review laws and regulations, and state standards.
Promote access to appropriate, effective, and quality treatment.
Monitor care management activities for undesirable performance or deviations from practice standards that may negatively affect consumers, and respond with follow-up, provider technical assistance, or referral to other MCO departments.
Notify members of adverse benefit determinations while preserving their due process rights.
Conduct routine follow-up to ensure consumers are engaged in treatment and services are being delivered as requested.
Document utilization review decisions in a computerized authorization management system.
Maintain professional licensure.
Participate in training as needed to stay informed about best practices for supporting individuals with MH/SUD/IDD.