Utilization Review Clinician - Behavioral Health

Utilization Review Clinician - Behavioral Health

The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Utilization Review Clinician to perform utilization reviews for behavioral health treatment to ensure that HPSM members receive necessary behavioral health care in a timely and cost-effective manner. Ensure that, initial and concurrent reviews for all treatment requests are completed within specified time frames using evidence based criteria for medical appropriateness to support the care or service under review. Coordinate clinical needs across the continuum of care by contacting and establishing links with physicians and other providers and community resources.

The essential duties and responsibilities will include the following: 

• Manage inpatient and outpatient mental health treatment authorization requests
• Determine if additional clinical treatment sessions are needed
• Attend Interdisciplinary meetings at hospitals for complex cases.
• Coordinate an interdisciplinary approach to support continuity of care. Provide utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed for members.
• Identify ways to add value to treatment plans and consulting with facility staff or outpatient care providers on those ideas
• Work collaboratively with facility and treatment partners to evaluate and provide feedback to providers regarding coordination of covered services.
• Responsible for the early identification and assessment of members for potential inclusion in a comprehensive case management program. Refer members for Case Management accordingly.
• Utilize appropriate resources to guide review decisions and document decisions clearly and concisely.
• Monitor, track, and report on all work conducted.
• Complete all required documentation and telephonic member follow-up within specified computer systems and within the required timeframes.
• Refer members to care coordination as the need is identified during the review process.
• Reconcile daily hospital census reports and face sheets against authorizations.
• In conjunction with the Care and Transitions team, provide care coordination and referral to services to ensure that a member’s needs are met.
• Participation in IDT/ICT meetings and clinical huddles as needed.
• Perform other duties as assigned

Requirements

Education and Experience:

• Master's degree in Social Work, Psychology, Counseling or Marriage or Family Counseling or above.
• Current unrestricted CA licensure as LMFT, LCSW or Psychologist.
• 2 years of experience in mental health and/or substance abuse treatment environment

Preferred Experience:

• Experience in Utilization review

Knowledge of: Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint. San Mateo County provider community and community resources. Medicare and Medi-Cal coverage requirements and regulatory guidelines.  Utilize Access, Microsoft Office programs; perform internet research. Managed Care processes, including use of Milliman Care guidelines or InterQual.  Working knowledge of all relevant federal, state, local and regulatory requirements.

Ability to: Work cooperatively with others.  Work as part of a team and support team decisions. Communicate effectively, both verbally and in writing.  Adapt to changes in requirements/priorities for daily and specialized tasks.  Ensure medical appropriateness and effective utilization of health care resources. Maintain timely compliance with all UM regulatory mandates. Ensure provider conformance to HPSM UM guidelines. Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies and the general public.  Communicate effectively, both verbally and in writing, with individuals from varying cultural and ethnic backgrounds.

Compensation and Benefits

Starting Compensation Range: - Depending on Experience

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s Medical, Dental and Vision coverage.  Employee pays a small portion of the dependent premiums (5%) for medical and dental benefits.  Additional HPSM benefits include fully paid life, AD&D, and LTD insurance; retirement plan (HPSM contributes equivalent of 10% of annual compensation); holiday and vacation pay; tuition reimbursement plan; onsite fitness center and more.