General Duties and Responsibilities of the BH Care Manager :

• Maintain a high level of ethical conduct while complying with HIPAA, Privacy, and Confidentiality laws and regulations
• Adhere to Health Plan, Behavioral Health and Health Services policies and procedures
• Be abreast on clinical knowledge related to ABA, mental health and developmental disabilities
• Effectively communicate, verbally and in writing, with providers, members, vendors, and other health care providers and in a timely, respectful and professional manner
• Function as a collaborative member of Health Services’ multi-disciplinary team
• Identify and report quality of care concerns to management and as directed, to appropriate CenCal Health department for follow up
• Support and collaborate with the management, medical management and health services team members in the implementation and management of Utilization Management, Case Management, Disease Management, Population Health, Care Coordination, and Care Transition activities
• As required, actively participate in the implementation, assessment, and evaluation of quality improvement activities as it relates to job duties
• Adhere to mandated reporting requirements appropriate to professional licensing requirements
• Refer members to complex medical case management when needs are primarily medical
• Refer members to case management, when needs are primarily medical or if member may meet criteria
• Comply with regulatory standards of governing agency
• Provide community resources as member indicates or when identified need
• Support and work collaboratively with the Medical Management and Health Services Management team in the implementation and management of UM/CM/DM/PH activities.
• Actively participate in the development, implementation and the evaluation of department initiatives with the intent to assess any measurable improvements to member’s quality of care 
• Keep abreast of health care benefits and limitations, regulatory requirements, disease processes, treatment modalities, community standards of patient care and standards of professional practice within license.
• Embrace innovative care strategies that are build value based programs

The BH Care Manager is responsible for Utilization Management and Care Coordination duties for members eligible for ABA services. Utilization Management (UM) responsibilities, in addition to the General Duties and Responsibilities noted above, but are not limited to:

• Act as a liaison primarily to providers and CenCal employees regarding UM processes and its operational standards as it relates to ABA services and related BHT services
• Timely review of request for referrals and authorization for ABA services, psychological testing and related BHT services
• Application and interpretation of established clinical guidelines and/or benefits limitations
• Accurate decision-making skills to support the appropriateness and medical necessity of requested BHT services
• Codes each diagnosis of service and procedures according to established policy and procedure
• Perform accurate and timely prospective (pre-service) reviews for ABA and BHT services
• Document clear and concise case review summaries.
• Compose appropriate and accurate draft notice of action, non-coverage, or other regulatory required notices to members and providers regarding UM decisions in supervision with the Medical Director and Director of Behavioral Health
• Assist Medical Director with benefit interpretation, obtaining additional medical necessity information and researching issues
• Accurate application and citation of sources used in decision-making
• Adhere to regulatory timeline standards for processing, reviewing, and completing reviews
• Review FBA Treatment plans and other provider documentation for compliance
• Review pending queues for referral and authorizations.
• Facilitate and assist members with accessing other medically necessary medical or mental health care through care coordination and education.
• Collaborate with contracted agencies and community based organizations to provide services not managed by the health plan.
• Effectively communicate verbally and in writing with primary care providers, members, authorized representatives, and other health care providers involved in the care of the member using a Solutions-Oriented Approach.
• Identify potential quality issues and fraud/waste/abuse.
• Entering and completing data tracking efficiently and accurately.
• Attend community meetings with stakeholders or providers as assigned.