Location
Jackson, MI | United States
Job description
General Summary:
Under the direction of the Utilization Management Director, this position authorizes services and assists in monitoring adherence of contracted providers to established site review protocols, access and service authorization criteria, and regional policy, to ensure appropriate access and effective/efficient use of behavioral health and substance use disorder (SUD) services. This position shall review the appropriateness of admissions and authorization requests, to confirm, through clinical review, the medical necessity of treatment services based on individual client needs, service eligibility, efficacy of proposed treatment (in comparison to other available treatment options), and treatment history. This position shall be involved in direct client contact, respond to requests for information and general referrals, review and make determinations on authorization requests, provide care management, wait-list management and follow-up. Responsible for carrying out all activities of the Pre-Paid Inpatient Health Plan (PIHP) in such a manner that fulfills the organization's mission and assures compliance with policies and procedures.
Essential Functions:
- Exercises independent clinical judgment and decision making in determining the ongoing eligibility of consumers for public mental health services and supports.
- Working knowledge of the principles and practices of healthcare coordination.
- Ensures the presence of documentation of clinical symptoms and the level of care suited for each service prior to authorization of service. Authorizes mental health services for children and adults within the LifeWays Provider Network based on medical necessity criteria, including functional assessment tools.
- Understands and applies working knowledge of clinical DSM 5 diagnoses and the symptomology to support the diagnosis.
- Completes utilization reviews (prospective, concurrent, targeted and retrospective) to manage the care of assigned populations using available data. Participates in the Clinical Record Review process.
- Provides technical assistance, training on processes and systems and clinical consultation as needed/requested internally and within LifeWays' Provider Network, independently or in collaboration with the LifeWays Clinical Training team.
- Acts as a liaison between Michigan Department of Health and Human Services (MDHHS) and LifeWays on application and oversight of Serious Emotional Disturbance Waiver (SEDW), Children's Waiver Program (CWP), and all State Hospital admissions.
- Maintains a thorough understanding of the Person-Centered Planning process, including documentation required and expectations for a well-developed treatment plan.
Upholds clear understanding of the Provider Network of services, both internal and external, including the scope of practice for each of these providers related to ensuring appropriate referral/request for service delivery.
- Participates as an active member in all committees as assigned that include but are not limited to Utilization Management Committee, Diversion Committee, Corporate Compliance Committee or other LifeWays inter-departmental committees.
- Meets Key Performance Indicators (KPIs) for job assignments as determined by LifeWays Leadership.
- Authorizes mental health services for other populations (child/inpatient/etc.) as needed to provide departmental coverage of utilization review within appropriate timelines.
- Participates in case-consultation with stakeholders, MDHHS, MSHN and providers as requested.
- Conducts site visits to crisis homes, residential facilities and LifeWays provider sites to complete utilization or clinical record reviews, assist in problem solving with service issues, or facilitate discharge planning as necessary. These meetings generally occur in Jackson and Hillsdale counties but travel within the State of Michigan may be necessary.
- Provides quality customer service when responding to inquiries regarding services, policies, and procedures by varying levels of staff and leadership across the organization and community.
- Communicates professionally while interacting with a variety of individuals, including guardians/consumers, providers and provider management, Board members, and community partners/stakeholders.
- Maintains oversight of programs/duties assigned, including electronic documentation in EMR, databases, or other means of tracking high priority cases, Specialized Residential, SEDW, CWP, and State Inpatient placements and notifies proper leadership/administration of trends and/or escalated cases/concerns.
- Upholds professional ethical standards governed by clinical licensure.
- Responsible for adherence to all Commission on Accreditation of Rehabilitation Facilities (CARF) and Michigan Department of Health and Human Services (MDHHS) standards.
- Maintains regular and predictable attendance.
Required Education/Certification/Licensure:
- Master's degree in Social Work, Counseling, or Psychology with full licensure (LMSW, LPC, or LP), will consider Limited License with the expectation of obtaining full licensure within two years of starting position.
- Maintain appropriate licensure with the State of Michigan.
- Ability to be credentialed as a Mental Health Professional according to Michigan PIHP/CMHSP Provider Qualifications.
- Maintain credentialing requirements for ongoing clinical privileges with LifeWays.
Preferred Education/Certification/Licensure:
- Full Licensure within the State of Michigan to ensure appropriate clinical expertise (LMSW or LPC)
Job tags
Salary
$56.16k - $77.42k
