Behavioral Health Care Coordinator, Utilization Management

About the Role

Responsible for carrying out discharge planning activities and medical necessity reviews on all behavioral health, alcohol & drug, and dual diagnosis members admitted for inpatient treatment, partial hospital programs, and external outpatient services utilizing established criteria and guidelines. Activities include onsite and telephonic review of services, referrals, coordination of transfers, eligibility and benefit reviews, discharge planning, identification of patients for case management, quality improvement reviews, education of members/families, providers, and hospital staff, and communication with inpatient care coordinators, case managers, home care reviewers, members, providers, Member Services, Claims, Contracts and Benefits - Appeals, and Risk Management.

Responsibilities

• Perform day-to-day Behavioral Health case management and review activities.
• Assess members using provider and hospital records to identify high-risk individuals for re-hospitalization or noncompliance with post-hospital treatment recommendations.
• Perform admission and concurrent reviews on all Behavioral Health inpatient admissions and Partial Hospital Program admissions using established guidelines and criteria.
• Conduct precertification and ongoing review of external outpatient Behavioral Health services; refer cases not meeting criteria to the appropriate review physician.
• Perform questionable benefit and eligibility reviews.
• Develop discharge care plans with inpatient and outpatient staff and coordinate follow-up appointments.
• Refer patients to the Complex Case Management Program as appropriate.
• Provide written and verbal correspondence to members regarding referrals in accordance with policy.
• Interact with physicians to ensure appropriate resource utilization while maintaining quality outcomes.
• Respond to requests from patients and families, including providing education when needed.
• Refer patients to home care review teams and/or social workers as appropriate.
• Ensure the appropriate level of care is delivered in the most suitable setting based on established criteria.
• Perform quality of care and service reviews using identified quality indicators.
• Coordinate and assist the Supervisor with ongoing physician education.
• Review monthly analysis of statistics (cost/benefit) with the Supervisor and adjust based on findings.
• Maintain knowledge of contract benefits, state and federal regulations, and laws affecting managed care and case/utilization management.
• Facilitate precertification and referral processes through effective communication with medical staff, nursing staff, complex case managers, and other departments.
• Assist in developing and revising guidelines, pathways, and protocols.
• Attend QRM Hospital UM meetings as requested.
• Investigate, identify, and report problems and inefficiencies in existing systems; recommend changes to the Supervisor.
• Participate in the coordination, planning, development, implementation, and maintenance of QRM policies and procedures under the guidance of the Supervisor.
• Monitor utilization trends and initiate recommendations to reduce utilization where appropriate.
• Refer cases identified as risk management, peer review, or quality issues to QAIR and Risk Management.
• Perform document review activities, including assessing medical necessity for admission/procedure, diagnoses, procedures performed, demographic data, and issuing letters of non-coverage when criteria are not met.
• Work cross-functionally with other departments to meet organizational goals.
• Maintain compliance with regional personnel policies, departmental policies, and Principles of Responsibility.
• Assist in investigating concerns and issues raised by Medical Office Administration, Customer Services, and Provider Relations.
• Limit access to protected health information (PHI) to the minimum necessary and maintain confidentiality in accordance with HIPAA privacy regulations.
• Report compliance issues and concerns promptly to the immediate supervisor or Director of Regional Compliance.

Requirements

• Minimum one (1) year of experience in utilization or case management, discharge planning, and quality improvement in a managed care setting.
• Minimum three (3) years of RN Clinical Nursing or social worker experience in the behavioral health field.
• B.S. in Nursing OR four (4) years of experience in a directly related field.
• High School Diploma or GED (General Education Development).
• Registered Professional Nurse License (Georgia) OR Licensed Clinical Social Worker (Georgia) OR Licensed Master Social Worker (Georgia).
• Working knowledge of federal, state, local, and regulatory requirements.
• Functional knowledge of computers and ICD/CPT4 coding.

Preferred Qualifications

• Master’s Degree or MSW.

Pay

$40.35 - $51.59 / hour

Schedule

• Full-time (40 hours per week).
• Shift: Day (Monday through Friday, 08:00 AM – 05:00 PM).
• Worker location: Onsite (Atlanta, Georgia).