Clinical/Behavioral Health Specialist, Utilization Management

POSITION SUMMARY

The Clinical Specialist reports to the Assistant Manager, Medical Management and provides clinical decision-making support and community resource coordination in support of Community Health Options Medical Management approach. This balances advocacy for the individual based on benefit design with stewardship for the entire individual and group membership through effective utilization management strategies. The incumbent supports Medical Management operational needs to ensure effective and efficient program coordination across the health continuum. The Clinical Specialist employs critical thinking skills to effectively manage complex medical and behavioral health presentations. This individual is nimble and consistently demonstrates ability to swiftly adapt and flex work assignments based on daily operational priorities to include appropriate referrals to coordinate Member-centric services. Responsible primarily for performing medical necessity reviews for appropriateness of authorization of behavioral health care services (IP/OP/PHP/IOP etc.) and medical necessity reviews of some medical services such as imaging and other outpatient medical services. Remote work is required. Must provide sufficient internet bandwidth to meet system operational needs and have a home office environment that protects the privacy and integrity of confidential information.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

• Consistently exhibits behavior and communication skills that demonstrate Health Options commitment to superior customer service.
• Efficiently coordinates medical services to facilitate Members receiving the right care, at the right time, in the right setting.
• Using approved evidence-based clinical criteria, reviews requests to determine if submitted clinical documentation supports medical necessity.
• Consults with or refers case to Medical Director for complex clinical presentation or medical necessity review.
• Appropriately identifies and refers cases to claim operations queue (i.e., subrogation, coordination of benefits, clinical research).
• Collaborates with the Care Management Team and ensures appropriate referrals are placed.
• Establishes relationships with local providers, health care organizations discharge planners/coordinators, and community resources, as applicable.
• Complete accurate and timely documentation according to established policies and procedures.
• Participates in quality improvement activities and professional development such as Interrater Reliability (IRR).
• Consistently references approved resources and follows established department procedures and workflows.
• Maintains confidentiality in all aspects of Member and proprietary company information.
• Ability to effectively deescalate Member and provider emotionally charged situations.
• Ability to maintain production levels and quality standards with minimal direct supervision.
• Performs additional duties as assigned.

JOB SPECIFIC KEY COMPETENCIES (KSAs)

• Proficient in English with verbal, written, interpersonal and public communications.
• Proficient with Microsoft Office products, typing proficiency, and ability to maintain accurate and timely completion of clinical documentation.

DIVERSITY, EQUITY, AND INCLUSION STATEMENT

Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces:

• Respectful, open communication and cooperation between all employees.
• Teamwork and participation, encouraging the representation of all groups and employee perspectives.
• Balanced approach to work culture through flexible schedules to accommodate varying needs of our people.
• Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other.

QUALIFICATIONS AND CORE REQUIREMENTS

• Completion of an accredited registered nursing (RN) or licensed practical nursing (LPN) degree program
• Minimum of one (1) year of experience in Utilization Management/Utilization Review
• Minimum of two (2) years of behavioral health clinical experience required.
• Current, unrestricted Maine Registered Nurse license (RN) or compact state RN license or Maine Licensed Practical Nurse (LPN) license or compact state LPN license required.
• Change resiliency.
• Experience with MCG Guidelines required.

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