Posted on: February 5, 2020
Utilization Manager Position Purpose: Perform duties to
authorize and review utilization of mental health and substance
abuse services provided in inpatient, outpatient and intermediate
care settings, provide and/or review intakes and initial
evaluations, brief focused treatment interventions, monitor quality
of care, collect and analyze utilization and cost of care data,
assist with discharge planning, arrange transportation; provide
member assistance and participate in special utilization projects.
Authorize, direct and monitor care for mental health and substance
abuse problems according to clinical information given by providers
and internal criteria for medical necessity and appropriateness of
care. Ensure compliance with all performance measures in regards to
appeals, denials, higher level of care admission certification and
concurrent review timeliness, Outpatient Treatment Report review
timeliness, readmissions, and others as indicated. Interact with
physicians and social workers for discharge planning. Direct and
coordinate follow-up to ensure plans for continuity of care and
adherence to HEDIS standards. Compile and report daily review
activity and facility statistics. Participate in quality
improvement activities, supporting network development and
interfacing with treatment facilities and the professional
community. Verify subscriber eligibility and existing benefits for
mental health and substance treatment, prior to authorizing all
levels of treatment including concurrent outpatient. Track benefit
usage and advise appropriate parties of exhaustion of benefits.
Interact with Medical Director or designee to discuss clinical
authorization questions and concerns regarding specific cases.
Education/Experience: Master's degree in Behavioral Health or RN.
3+ years experience in psychiatric and/or substance abuse health
care settings including utilization review. Working knowledge of
utilization review procedures, mental health and substance abuse
community resources and network providers. License/Certification:
Required to have license to practice independently, and/or have
obtained the state required licensure as outlined by the applicable
state. This includes but is not limited to licenses such as LPC,
LCSW, LMFT, LMHC, LIMHP, and RN. Sunflower Health Plan Only: LCPC,
LSCSW, LCMFT, LCP, LCAC, APRN, or PMH-APRN or similar state license
required. Centene is an equal opportunity employer that is
committed to diversity, and values the ways in which we are
different. All qualified applicants will receive consideration for
employment without regard to race, color, religion, sex, sexual
orientation, gender identity, national origin, disability, veteran
status, or other characteristic protected by applicable law.
Clinical & Nursing USA-Texas-McAllen USA-Texas-El Paso Superior
Keywords: Centene, McAllen , Utilization Manager, Executive , Mcallen, Texas
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