Case Manager 3

About the role

The Behavioral Health Concurrent Review Clinician utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.

Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services

Fundamental Components include

• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
• Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care
• Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)
• Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment
• Identifies members who may benefit from care management programs and facilitates referral
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization
• 3-5 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
• Must be a Licensed Mental Health Professional with unrestricted LA state license. LADC or LAC (Licensed Addiction Counselor)

Additional Job Details

Experience and knowledge required in clinical guidelines, systems and tools i.e., Milliman, LOCUS, ASAM

Knowledge of provider networks and delivery, ability to interface with providers

• Possesses sound clinical judgment
• Strong organizational skills with an attention to detail
• Ability to work independently and on a team
• Ability to work with all levels of management
• Strong documentation skills and broad based clinical knowledge
• Behavioral health and physical health integrated care experience
• Positions may require working on-site

• Self-motivated and confident making clinical decisions, ability to influence and shape clinical outcomes
• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
• Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
• Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
• Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
• Typical office working environment with productivity and quality expectations.

Qualifications

Required for the openings: Managed care/utilization review experience strongly preferred

Additional Information

having Healthcare reimbursement knowledge along with medical billing and collection.