The Behavioral Health Concurrent Review Clinician utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services
Fundamental Components include:
- Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
- Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care
- Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)
- Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment
- Identifies members who may benefit from care management programs and facilitates referral
- Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization
- 3-5 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
- Must be a Licensed Mental Health Professional with unrestricted LA state license. LADC or LAC (Licensed Addiction Counselor)
Additional Job Details:
- Experience and knowledge required in clinical guidelines, systems and tools i.e., Milliman, LOCUS, ASAM
- Knowledge of provider networks and delivery, ability to interface with providers
- Possesses sound clinical judgment
- Strong organizational skills with an attention to detail
- Ability to work independently and on a team
- Ability to work with all levels of management
- Strong documentation skills and broad based clinical knowledge
- Behavioral health and physical health integrated care experience
- Positions may require working on-site
- Self-motivated and confident making clinical decisions, ability to influence and shape clinical outcomes
- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
- Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
- Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
- Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
- Typical office working environment with productivity and quality expectations.
Required for the openings:
- Managed care/utilization review experience strongly preferred
- Must be a Licensed Mental Health Professional with unrestricted LA state license. LADC or LAC (Licensed Addiction Counselor)
having Healthcare reimbursement knowledge along with medical billing and collection.
