Duties and responsibilities

• Conducts pre-certification, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.
• Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
• Applies clinical knowledge to work with facilities and providers for care coordination. May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.
• Educates the member about plan benefits and contracted physicians, facilities and healthcare providers.
• Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications.
• Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.

Qualifications:

• 1-2 years of clinical or utilization review experience; or any combination of education and experience, which would provide an equivalent background.
• Experience working with substance use and mental health in a treatment center preferred
• Able to maintain a professional manner with staff, clients, and visitors.
• Able to work in a fast paced setting, under pressure, and maintain open, and proper communication.
• Must be fluent in speaking, reading, and writing English.
• Able to write routine reports and correspondence.
• Ability to speak effectively before groups of clients or employees of an organization.
• Ability to relate harmoniously with staff and clients of diverse ethnic and economic backgrounds
• Experience in providing direct services to individuals, families and groups.
• Good Computer skills. Ability to navigate an Electronic Health Records System. Kipu experience a plus.
• Demonstrate professionalism, and strong boundaries with the clients.

Hiring Requirements:

1. Hiring is contingent upon completion of a Background Check, TB test, and clearance on a drug screen and pre-employment physical. Current First Aid and CPR certification or willing to obtain upon hire.
2. For the mental health and eating disorder programs additional requirements include receiving DOJ/FBI fingerprint clearance or an exemption and a submission of a signed Criminal Record Statement (LIC 508). Clean Background is required.