Location
Wilmington, NC | United States
Job description
LOCATION: Remote – must live in North Carolina or within 40 miles of the NC border.
GENERAL STATEMENT OF JOB The Mental Health/Substance Use (MH/SU) Care Reviewer is responsible for facilitating the review of service authorization requests and accompanying documents to ensure individuals are receiving the most appropriate services at a given time. This position screens authorization requests for completeness, recommends an administrative denial to the Licensed Care Managers for some requests based on review check- sheets, and refers requests that require clinical review to Licensed MH/SU Utilization Management Clinicians.
ESSENTIAL JOB FUNCTIONS Review of Service Authorization Requests: - Ensure all required documents are submitted with Service Plans and Authorization Requests (SARS) for specific benefit plans
- Review of plan and service requests for completeness
- Collection and transfer of non-clinical data
- Gather clinical information but does not engage in the evaluation or interpretation of clinical information
- Consult with licensed clinical staff when performing initial screening activities
- Approve requests and plans based on review check-sheets
- Refer service authorization requests to MH/SU Utilization Management Clinicians for clinical review
- Make recommendations to Administratively deny incomplete requests
- Make recommendations to the MH/SU Utilization Management Clinicians to submit pharmacy consultations for review for members that meet criteria
- Return invalid requests to providers via “unable to process” function
Monitor the Delivery of Monitored Services: - Identify provider training needs; provide training as needed and requested
- Identify and document service gaps and deficiencies in access to services
- Contact providers to gather information about the delivery of services between authorization reviews
Other Duties as Assigned. KNOWLEDGE, SKILL & ABILITIES - Knowledge of the assessment and treatment of developmental disabilities, with or without co-occurring mental illness, is a necessity.
- Ability to learn and understand legal, waiver and program practices/requirements and apply this knowledge in problem-solving and responding to questions/inquiries.
- Exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts and established processes.
- Problem solving, negotiation and conflict resolution skills are essential to balance the needs of both internal and external customers.
- Detail oriented, able to independently organize multiple tasks and priorities, and to effectively manage an assigned caseload under pressure of deadlines.
- Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) and Vaya information system.
QUALIFICATIONS & EDUCATION REQUIREMENTS Bachelor’s degree in Special Education, Psychology, Social Work or related Human Services area, and
- 2 years of post-degree professional experience.
- Quality as a QP Mental Health/Substance Use for the population served.
PHYSICAL REQUIREMENTS: - Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
- Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists, and fingers.
- Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
- Mental concentration is required in all aspects of work.
RESIDENCY REQUIREMENT: This position is required to reside in North Carolina or within 40 miles of the North Carolina border.
SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.
DEADLINE FOR APPLICATION: Open Until Filled
APPLY: Vaya Health accepts online applications in our Career Center, please visit
Vaya Health is an equal opportunity employer.
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