GENERAL SUMMARY
Provides case management services for the behavioral health unit through evaluation and review of inpatient and outpatient behavioral health treatments for medical necessity, emergency status, and quality of care that efficiently uses healthcare resources to achieve optimum member outcomes.
ESSENTIAL RESPONSIBILITIES
- Provides case management services including pre-certification and concurrent review to assigned cases in compliance with the available benefit structure and within the available continuum of care.
- Evaluates acuity for medical necessity and makes appropriate utilization determination. Provides triage and assessment of members or others acting on member’s behalf who request non-routine behavioral health care. Utilizes medical necessity criteria when performing reviews, and refers to peer reviewer when criteria are not met.
- Assists in developing cost-effective care plans for high-risk, high-cost cases by working with behavioral healthcare providers, members, and their families. Implements intensive case management policies and procedures for affected members.
- Seeks out a physician or psychologist reviewer for consultation and determination of utilization management decisions as needed.
- Records and resolves member inquiries and complaints in accordance with company policies and procedures.
- Maintains documentation in member file in an acceptable format to ensure accurate documentation and reporting.
- Assists in the collection of quality improvement and utilization improvement data as directed.
- Participates in after-hours on-call schedule as needed.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Professional licensure required in state where job duties are performed; Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Mental Health Counselor (LMHC), Licensed Master Social Worker (LMSW), Licensed Professional Counselor (LPC), licensed psychologist, Licensed Practical Nurse (LPN) or Registered Nurse (RN).
- Previous (2-5 years) clinical experience in the delivery of behavioral health care services.
- Previous experience working in a managed care environment preferred.
- Demonstrated written and verbal communication skills.
- Ability to use standard computer software packages and applications.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: St. Louis, MO, US
Organization: 51000 - MHNet Specialty Services, LLC
Schedule: Full-time
Job Posting: 2013-02-05 00:00:00.0
Job ID: 1310432