Utilization Manager
Posted on: 6 Feb 2021
Jackson, MS
Job Description
Position Purpose:
Perform duties to authorize and review utilization of mental health and substance abuse services provided in inpatient, outpatient and intermediate care settings, provide and/or review intakes and initial evaluations, brief focused treatment interventions, monitor quality of care, collect and analyze utilization and cost of care data, assist with discharge planning, arrange transportation; provide member assistance and participate in special utilization projects.
* Authorize, direct and monitor care for mental health and substance abuse problems according to clinical information given by providers and internal criteria for medical necessity and appropriateness of care.
* Ensure compliance with all performance measures in regards to appeals, denials, higher level of care admission certification and concurrent review timeliness, Outpatient Treatment Report review timeliness, readmissions, and others as indicated.
* Interact with physicians and social workers for discharge planning.
* Direct and coordinate follow-up to ensure plans for continuity of care and adherence to HEDIS standards.
* Compile and report daily review activity and facility statistics.
* Participate in quality improvement activities, supporting network development and interfacing with treatment facilities and the professional community.
* Verify subscriber eligibility and existing benefits for mental health and substance treatment, prior to authorizing all levels of treatment including concurrent outpatient.
* Track benefit usage and advise appropriate parties of exhaustion of benefits.
* Interact with Medical Director or designee to discuss clinical authorization questions and concerns regarding specific cases.
Education/Experience:
Master's degree in Behavioral Health or RN. 3+ years experience in psychiatric and/or substance abuse health care settings including utilization review. Working knowledge of utilization review procedures, mental health and substance abuse community resources and network providers.
License/Certification:
Required to have license to practice independently, and/or have obtained the state required licensure as outlined by the applicable state. This includes but is not limited to licenses such as LPC, LCSW, LMFT, LMHC, LIMHP, and RN.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Centene
St Louis, MO
Centene Corporation operates as a diversified and multi-national healthcare enterprise that provides programs and services to under-insured and uninsured individuals in the United States. The company’s Managed Care segment offers health plan coverage to individuals through government subsidized programs, including Medicaid, the State children’s health insurance program, long-term services and support, foster care, and medicare-medicaid plans, which covers dually eligible individuals, as well as aged, blind, or disabled programs. Its health plans include primary and specialty physician care, inpatient and outpatient hospital care, emergency and urgent care, prenatal care, laboratory and X-ray, home-based primary care, transportation assistance, vision care, dental care, telehealth, immunization, specialty pharmacy, therapy, social work, nurse advisory, and care coordination services, as well as prescriptions, limited over-the-counter drugs, medical equipment, and behavioral health and abuse services.
This segment also offers various individual, small group, and large group commercial healthcare products to employers and directly to members in the Managed Care segment.Its Specialty Services segment provides pharmacy benefits management services; health, triage, wellness, and disease management services; and vision and dental, and management services, as well as care management software that automate the clinical, administrative, and technical components of care management programs. This segment offers its services and products to state programs, correctional facilities, healthcare organizations, employer groups, and other commercial organizations. The company provides its services through primary and specialty care physicians, hospitals, and ancillary providers. Centene Corporation was founded in 1984 and is headquartered in St. Louis, Missouri.
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IndustryHealthcare
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No. of Employees47, 300
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Website
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Jobs Posted349
