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Utilization Case Manager - Health Plan

San Diego, CA · Healthcare
The Care Manager is responsible for the assessment, reassessment, care planning and coordination of care and services including ongoing monitoring of an appropriate and effective person-centered care plan, member education and care management.

Responsibilities:
  • Under general supervision, and in collaboration with other members of the clinical team, authorizes and reviews utilization of mental health and substance abuse services provided in inpatient and/or outpatient care settings.
  • Collects and analyzes utilization data.
  • Provides telephone triage on a que, crisis intervention and emergency authorizations as assigned. Authorizations  for services and creating provider lists that are sent out to members to help locate providers; Team members receive an average of 1-2 calls per hour.
  • Assists with discharge planning and care coordination.
  • Provides member assistance with mental health and substance abuse issues, and participates in special quality improvement projects.
  • Monitors inpatient and/or outpatient level of care services related to mental health and substance abuse treatment to ensure medical necessity and effectiveness.
  • Conducts initial and concurrent review for prior authorization of higher levels of care against medical necessity criteria.
  • Develops individualized care plans for high and moderate stratified members in the Medicaid, Medicare, and Whole Health markets.
  • Oversees the work of its assigned care support team and work with non-licensed support staff to meet standards of care and performance set by Member Market Leads and the Care Management Center of Operational Excellence (CoOE) Lead. 

Requirements:
CA independent behavioral health (LCSW, LMFT, LPCC) or RN licensure
 Master’s BH or Bachelor’s/RN with 5 years post degree experience in healthcare, behavioral health, psychiatric and/or substance abuse health care setting.
Behavioral Health case management, UM, Triage REQUIRED
Possesses clinical knowledge, understands best practices and continuous learning skills, review member records, and work in conjunction with primary care, community benefits, and other support opportunities to develop a long term care plan to guide the member through their mental health care.

100% Remote position eligible for full benefits including: medical, dental, vision, short/long term disability, life, 401k, paid time off, holidays, and more.
 
 
 
Contact information:
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Recruiter
Max Populi, LLC
4628 Bayard Street, #207
Pittsburgh, PA 15213-2750
Tel: (412) 567-5279
Fax: (412) 567-5198
e-mail: jobs@maxpopuli.com
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