Utilization Management Specialist - Remote / Telecommute

Job Overview:

Pay Range: $46.76hr - $51.76hr

Requirement/Must Have:

• Master's Degree in Psychology or Social Work.
• 5+ years of clinical experience.
• LCPC – Licensed Clinical Professional Counselor or LCSW-C - Licensed Clinical Social Worker license in MD, DC, or VA.
• Working knowledge of managed care and behavioral health delivery systems.
• Experience in direct treatment of both substance use and mental health focused treatment.
• Strong assessment skills with the ability to make rapid connection with members telephonically.
• Ability to work effectively with large amounts of confidential member data and PHI.
• Ability to prioritize workload during heavy workload periods.
• Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility.
• Proficiency in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint.
• Excellent analytical and problem-solving skills to judge appropriateness of services and treatments on a case by case basis.
• Strong verbal and written communication skills.

Responsibilities:

• Perform prospective, concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage.
• Analyze clinical information, contracts, mandates, medical policy, and evidence-based research to determine appropriateness of clinical services.
• Determine medical necessity by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM, and Medicare Guidelines.
• Follow NCQA Standards and departmental SOPs to manage member assignments.
• Conduct research and analysis of pertinent diseases, treatments and emerging technologies to support decisions and recommendations made to medical directors.
• Collaborate with medical directors, sales, marketing, contracting, and provider services to determine appropriate benefit application.
• Coordinate non-par provider/facility case rate negotiations between Provider Contracting and facilities.
• Offer assistance to members and providers for alternative settings for care.
• Research and present educational topics related to cases, disease entities, and treatment modalities to interdepartmental audiences.

Nice to Have:

• 2+ years of Care Management experience.
• Thorough knowledge of clinical guidelines, medical policies and accreditation and regulatory standards.
• Working knowledge of IT and Medical Management systems.

Skills:

• Utilization Management.
• Behavioral Health.
• Clinical Assessment.
• Milliman Care Guidelines.
• ASAM Guidelines.
• Medicare Guidelines.
• Microsoft Office.
• Excel.
• PowerPoint.
• Case Management.
• Medical Necessity Review.

Qualification And Education:

• Master's Degree in Psychology or Social Work.
• LCPC or LCSW-C licensure in MD, DC, or VA.