Utilization Management Specialist

Licenses/Certifications

LCPC – Licensed Clinical Professional Counselor – MD, DC, or VA license required

LCSW-C - Licensed Clinical Social Worker – MD, DC, or VA license required

*Business Justification: BH um specialist is required to staff upcoming change to begin prior authorization of outpatient behavioral health services which are not managed currently.

RFQ 51517 (LCPC) Spec, Utilization Management - 6+ Months Contract to Hire - 100% Remote DMV Local (every Wednesday meeting in Office) - 2 Interviews (One Virtual and One In-Person)

• Master's Degree Required
• NO Registered Nurses
• Client is looking for licensed behavioral health clinician Licensed Clinical Professional Counselor or Licensed Clinical Social Worker (LCPC or LCSW) in MD, DC, or VA to work as a Behavioral Health Utilization Management Specialist.
• This specialist will perform prospective, concurrent, and retrospective reviews to determine medical necessity, appropriateness of care, authorization, and benefit coverage for both medical and behavioral health services.
• They must apply managed care and behavioral health delivery knowledge along with guidelines such as Milliman, ASAM, Apollo, Medicare, NCQA, medical policy, contracts, and regulatory standards.
• The role requires strong clinical assessment, critical thinking, research and analytical skills, communication, multitasking, PHI confidentiality, and proficiency with web-based systems and Microsoft Office/Excel.
• The client specifically needs this person to support a new prior authorization process for outpatient behavioral health services, collaborate with medical directors and other departments and have direct treatment experience in both substance use and mental health care.

KEY SKILLS: LCPC or LCSW, Licensed in MD, DC or VA and Master's Degree, Managed Care and GuidingCare

NOTE: Look for someone who is a LCPC or LCSW-C (License - MD, DC, or VA) with managed care and behavioral health utilization management experience to perform prior authorization and medical necessity reviews for medical and behavioral health services while supporting a new outpatient behavioral health prior authorization program.

Job Description: PURPOSE:

Utilizing key principles of utilization management, the Behavioral Health Utilization Management Specialist will perform prospective, concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage. Leveraging clinical expertise and critical thinking skills, the Behavioral Health Utilization Management Specialist, will analyze clinical information, contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements contribute to determination of appropriateness and authorization of clinical services both medical and behavioral health.

ESSENTIAL FUNCTIONS:

50% Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, CareFirst Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all CareFirst lines of business to include Commercial, FEP, and Medicare primary and secondary policies.

30% Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts to assist with benefit determination.

20% Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care. Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable

accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education Level: Master's Degree

Education Details: Psychology or Social Work

Experience: 5 years Clinical experience required

2 years Care Management Required

In Lieu of Education n/a - education/licensure is requirement

Qualifications

Working knowledge of managed care and behavioral health delivery systems.

Thorough knowledge of CareFirst clinical guidelines, medical policies and accreditation and regulatory standards

Working knowledge of CareFirst IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource.

Experience in direct treatment of both substance use and mental health focused treatment.

Knowledge, Skills and Abilities (KSAs)

Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues, Proficient

Must have strong assessment skills with the ability to make rapid connection with Member telephonically., Proficient

Must be able to work effectively with large amounts of confidential member data and PHI, Expert

Must be able to prioritize workload during heavy workload periods, Proficient

Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility, Advanced

Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint, Proficient

Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis, Proficient