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Utilization Management, Remote 

EOE StatementWe are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.

Remote position.

Duties include:

• Performs telephonic care review and authorization determinations for prospective, concurrent, and discharge review with psychiatric and substance use treatment facilities as assigned.

• Determines appropriate level of care related to mental health and substance use treatment for members based on insurance medical necessity level of care criteria.

• Consults with the treatment team when requests for services do not meet medical necessity criteria.

• Interacts with Physician Advisors to discuss clinical/authorization questions, alternative treatment options, and concerns regarding specific cases. • Provides information to members and providers regarding mental health and substance use benefits and community treatment resources. • Collaborate with insurance physicians to complete physician reviews as needed for appropriateness and effectiveness of treatment to determine medical necessity criteria.

• Communicate notification of determinations and appeal rights to assigned facility, patient, and/or family.

• Create and manage patient files to document review outcomes and determinations.

• Document outcomes in the billing platform system for claim submission. • Functions as a clinical resource for the multi-disciplinary care team of assigned facility on an ongoing basis to maximize the quality of patient care while achieving effective medical cost management and desired outcome. • Collaborate with other departments at SJHIA as needed to ensure authorization and assigned facility information is accurate for claims submission purposes.

• Manages work in accordance with the Department.

• Perform any additional duties that arise to support the needs of the Department.

Position Requirements

Minimum Qualifications

• Master’s Prepared Mental Health Professional (Social Worker, Mental Health Counselor, Marriage and Family Therapist) with State License (e.g., LCSW, LMSW, LMFT, and related clinical/case management experience.

• 5 years’ experience in substance abuse and behavioral health setting. • Behavioral health and substance abuse clinical experience and knowledge of the medications used as standard practices related to diagnosis and treatment.

• Strong clinical knowledge in the subject area and standard practices in the treatment of mental health, and substance use disorders.

• Knowledge of the impact of psychosocial stressors and comorbid health conditions on mental health and substance use disorders.

• Demonstrated professional writing and electronic documentation along with clear and concise telephonic assessment skills.

• Ability to multitask and work as part of a team to meet the Department's goals and needs.

• Must possess computer skills including the ability to navigate Outlook, Excel, and Word programs.

Preferred Qualifications

• 5 plus years of experience post-master’s program in a clinical setting working with high-risk groups such as persons with serious mental illness and co-occurring medical or substance use disorders, persons with first episode psychosis, individuals in need of behavioral health services, individuals involved with multiple service systems.

• Knowledge of rehabilitation programs, community-based, recovery-oriented services, and community resources such as sober living, supported housing, mobile crisis, wrap-around services, and involuntary commitment process.

• Managed healthcare/utilization review experience across a variety of treatment settings for high-risk, complex populations.

• Knowledge of ASAM criteria.

• Basic knowledge of medical necessity criteria put forth by insurance carriers.


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