Case Manager 3

The Behavioral Health Concurrent Review Clinician utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.

Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services
Fundamental Components include:

• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
• Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care
• Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)
• Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment
• Identifies members who may benefit from care management programs and facilitates referral
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization
• 3-5 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
• Must be a Licensed Mental Health Professional with unrestricted LA state license. LADC or LAC (Licensed Addiction Counselor)

Additional Job Details:

• Experience and knowledge required in clinical guidelines, systems and tools i.e., Milliman, LOCUS, ASAM
• Knowledge of provider networks and delivery, ability to interface with providers
• Possesses sound clinical judgment
• Strong organizational skills with an attention to detail
• Ability to work independently and on a team
• Ability to work with all levels of management
• Strong documentation skills and broad based clinical knowledge
• Behavioral health and physical health integrated care experience
• Positions may require working on-site
• Self-motivated and confident making clinical decisions, ability to influence and shape clinical outcomes
• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
• Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
• Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
• Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
• Typical office working environment with productivity and quality expectations.

Required for the openings:

• Managed care/utilization review experience strongly preferred
• Must be a Licensed Mental Health Professional with unrestricted LA state license. LADC or LAC (Licensed Addiction Counselor)

having Healthcare reimbursement knowledge along with medical billing and collection.