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. Assists with discharge planning and care coordination. Provides member assistance with mental health and substance abuse issues, and participates in special quality improvement projects.
ESSENTIAL FUNCTIONS: - Monitors inpatient and/or outpatient level of care services related to mental health and substance abuse treatment to ensure medical necessity and effectiveness. - Provides telephone triage, crisis intervention and emergency authorizations as assigned. - Performs concurrent reviews for inpatient and/or outpatient care and other levels of care as allowed by scope of practice and experience. In conjunction with providers and facilities, may develop discharge plans and oversee their implementation. May also perform quality clinical reviews while educating and making appropriate interventions to advance the care of the member in treatment. - Provides information to members and providers regarding mental health and substance abuse benefits, community treatment resources, mental health managed care programs, andcompany policies and procedures, and criteria. - Interacts with Physician Advisors to discuss clinical and authorization questions and concerns regarding specific cases. - Participates in quality improvement activities, including data collection, tracking, and analysis. - Maintains an active work load in accordance with National Care Manager performance standards. Works with community agencies as appropriate. Proposes alternative plans of treatment when requests for services do not meet medical necessity criteria. Participates in network development including identification and recruitment of quality providers as needed. Advocates for the patient to ensure treatment needs are met. Interacts with providers in a professional, respectful manner that facilitates the treatment process.
Education: Master’s Degree
Field(s) of study: Masters or Doctoral Degree in behavioral health related field
Experience: Minimum 2 years of experience post degree in healthcare, behavioral health, psychiatric and/or substance abuse health care setting
Industry: Managed Care Other: Good organization, time management and communication skills; knowledge of utilization management procedures, mental health and substance abuse community resources and providers; knowledge and experience in inpatient setting; ability to function independently and as a team member; knowledge of DSM IV or most current diagnostic edition. Ability to analyze specific utilization problems, plan and implement solutions that directly influence quality of care.
Computer Skills: Ability to use computer systems Licenses, Certifications, etc.: Independent behavioral health licensure to practice in the State of CA. (MFT, LCSW, LPCC, Psychologist) and meet Magellan's credentialing requirements.