Utilization Management Behavioral Health
About The Position
This position is a hybrid role that combines the roles and expertise of Utilization Review and Care management. This role is essential in ensuring that members receive high-quality, cost-effective care. Overall, utilization management is an essential process that not only ensures the medical necessity of care but also assists in monitoring and controlling healthcare costs while prioritizing member safety. These processes involve detailed assessments, evidence-based guidelines, and coordination among various healthcare professionals to achieve optimal outcomes for members. The ideal candidate will possess a strong understanding of utilization management principles, as well as a solid foundation in healthcare operations and regulatory compliance. Candidates will apply expertise to review medical records and treatment plans for individuals with specific conditions or diagnosis including medical and behavioral health conditions to ensure that services are medically necessary, appropriate, and cost-effective. To show our commitment to you and to assist with your transition into our organization, we will also offer a $2500 sign on bonus to those that have 1+ year of experience. (External LCSW applicants only.)
Requirements
- Master’s degree in Social Work
- Current licensure or Certification in Utah: LCSW
- Candidates may be required to obtain a licensure in others states in Select Health region within 90 days of employment.
- Demonstrated clinical expertise and experience in related behavioral health field.
- Minimum 1 year experience in Utilization management or closely related field including: Utilization Review, Case Management, discharge planning, managed care, health promotion, health coaching, behavioral health, or Patient Educator job role.
- Intermediate computer and hardware set-up, ability to customize computer settings and use multiple monitors and capable of independent troubleshooting internet and applications.
Nice To Haves
- Three years of experience and expertise working in clinical Behavioral Setting or Utilization Management.
- Ability to work independently and be flexible in a rapidly changing environment.
- Demonstrated excellent written and verbal communication skills.
- Experience working successfully in a remote environment or using Advanced Microsoft Suite, including Teams (chat, whiteboard, task tracking) & Outlook; Ability to work independently, be self-motivated, have a positive attitude, and be flexible in a rapidly changing environment.
- Knowledge of healthcare insurance and utilization review processes.
- Knowledge of regulatory requirements, such as NCQA, CMS, and state-specific regulations and legislation related to field.
- Ability to travel as needed.
Responsibilities
- Utilization Review and Care Management of members with specific treatment plans, conditions, or diagnosis including medical and behavioral health conditions
- Provide ongoing training and support to families and caregivers.
- Collect, analyze, and interpret data to evaluate the effectiveness of interventions.
- Stay current with the latest research and best practices in assigned population.
- Inform Select Health Medical and Behavioral Health policy and procedure.
- Peer to Peer and Peer review to evaluate and influence the work of others in the field to ensure adherence to ethical standards, best practices, and regulatory requirements.
- Occasional travel to provider locations within Select Health region.
- Review medical records to determine the medical necessity of services.
- Evaluate the appropriateness of procedures, diagnostic assessments, functional behavior assessments, and treatment plans.
- Make timely and informed determinations about the medical necessity and appropriateness of services.
- Adhere to regulatory requirements, payer guidelines, and ethical standards.
- Facilitate Communication, Organize Collaborative Meetings, and Resolve Conflicts with healthcare providers to ensure coordinated member care.
- Communicate with members, families, and insurance representatives.
- Conduct comprehensive assessments of members' needs.
- Develop and implement individualized care plans.
- Educate and empower members and families.
- Advocate for members' rights and access to care.
- Monitor and evaluate the effectiveness of care plans.
Benefits
- Sign on bonus ($2500 for those with 1+ year of experience, External LCSW applicants only)
- Comprehensive benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.
- PEAK program supports caregivers in the pursuit of their education goals and career aspirations by providing up-front tuition coverage paid directly to the academic institution. The program offers 100+ learning options to choose from, including undergraduate studies, high school diplomas, and professional skills and certificates. Caregivers are eligible to participate in PEAK on day 1 of employment.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
