Kaiser Permanente
Specialist, Utilization Management-Mental Health-NE
Ensure consistent application and management of Kaiser Permanente mental health and chemical dependency benefits. Essential Responsibilities: Benefit payment authorizations. Manage behavioral health benefits by providing medical necessity determinations. Member contact. Member contact may occur for a variety of reasons which can include benefit explanations, resource identification and appointment scheduling. Payment denials. Kaiser policies are followed for all benefit payment denials. UM coordinator is always available to explain a payment denial to providers and members. Consultations. Consultations are provided to internal and external providers regarding medical necessity interpretation, benefits, covered services, contracted providers and available resources that meet the clinical needs of the Kaiser member. Fraud and abuse. Responsibility for ensuring the appropriate expenditure of healthcare dollars in accordance with rules and regulations set forth in Kaiser policies, licensing and credentialing entities and all state and federal laws and regulations. Ensuring continuity of care by facilitating communication between service providers regarding treatment planning, intervention, outcomes, and recommendations. Care coordination. Ensuring upon discharge from higher levels of care that all members have an appropriate discharge plan within HEIDIS guidelines. On-call rotation as assigned to cover pre-authorizations for non-business hours. Basic Qualifications: Minimum three (3) years of experience working directly or indirectly with individuals with mental health or chemical dependency conditions, which would include diagnosing, treating or managing. Minimum two (2) years of experience in utilization management and discharge planning. Education: Masters degree in mental health, social work or closely related field from an accredited institution. Additional Requirements: Understanding of medical necessity criteria and its application. Knowledge of DSM-IV diagnoses, community standards of treatment and treatment interventions for mental health, addictions and co-occurring disorders. Familiarity with community resources. Knowledge of how behavioral health benefits work. Good clinical judgment in assessing the clinical needs of patients and matching those needs to the appropriate level of care. Demonstrated ability to develop successful interpersonal relationships and earn the respect of physicians, nurses, therapists and other personnel. Able to participate as a team member, but demonstrates high level of self-motivation and ability to work independently. Excellent oral and written communication skills. Excellent problem solving abilities, detail oriented, and very organized. Use medical criteria for UM decision-making and education with patients, providers, and community providers. Ability to effectively utilize computerized medical records. Ability to use Microsoft Office software. Ability to use analytical software. Ability to collect, analyze, and report statistically meaningful quality and utilization data. Excellent written and verbal communication skills; presentation skills; analytical problem-solving skills; well developed project management skills; and competent quantitative skills.
Ensure consistent application and management of Kaiser Permanente mental health and chemical dependency benefits. Essential Responsibilities: Benefit payment authorizations. Manage behavioral health benefits by providing medical necessity determinations. Member contact. Member contact may occur for a variety of reasons which can include benefit explanations, resource identification and appointment scheduling. Payment denials. Kaiser policies are followed for all benefit payment denials. UM coordinator is always available to explain a payment denial to providers and members. Consultations. Consultations are provided to internal and external providers regarding medical necessity interpretation, benefits, covered services, contracted providers and available resources that meet the clinical needs of the Kaiser member. Fraud and abuse. Responsibility for ensuring the appropriate expenditure of healthcare dollars in accordance with rules and regulations set forth in Kaiser policies, licensing and credentialing entities and all state and federal laws and regulations. Ensuring continuity of care by facilitating communication between service providers regarding treatment planning, intervention, outcomes, and recommendations. Care coordination. Ensuring upon discharge from higher levels of care that all members have an appropriate discharge plan within HEIDIS guidelines. On-call rotation as assigned to cover pre-authorizations for non-business hours. Basic Qualifications: Minimum three (3) years of experience working directly or indirectly with individuals with mental health or chemical dependency conditions, which would include diagnosing, treating or managing. Minimum two (2) years of experience in utilization management and discharge planning. Education: Masters degree in mental health, social work or closely related field from an accredited institution. Additional Requirements: Understanding of medical necessity criteria and its application. Knowledge of DSM-IV diagnoses, community standards of treatment and treatment interventions for mental health, addictions and co-occurring disorders. Familiarity with community resources. Knowledge of how behavioral health benefits work. Good clinical judgment in assessing the clinical needs of patients and matching those needs to the appropriate level of care. Demonstrated ability to develop successful interpersonal relationships and earn the respect of physicians, nurses, therapists and other personnel. Able to participate as a team member, but demonstrates high level of self-motivation and ability to work independently. Excellent oral and written communication skills. Excellent problem solving abilities, detail oriented, and very organized. Use medical criteria for UM decision-making and education with patients, providers, and community providers. Ability to effectively utilize computerized medical records. Ability to use Microsoft Office software. Ability to use analytical software. Ability to collect, analyze, and report statistically meaningful quality and utilization data. Excellent written and verbal communication skills; presentation skills; analytical problem-solving skills; well developed project management skills; and competent quantitative skills.