Behavioral Health Utilization Review Specialist - LICSW or RN
Health Care that Starts with You!
Join a truly mission-driven organization! Independent, nonprofit UCare is recognized as one of the Minnesota's leading health plans. We provide more than 225,000 members across Minnesota and western Wisconsin with the health coverage plans and services they need to maintain and improve their health. The innovative coverage we create makes a difference for Medicare-eligible individuals, individuals and families enrolled in Minnesota Health Care Programs, such as MinnesotaCare and Medical Assistance, and disabled adults with special health care needs. UCare is growing in size, membership, products, geographic coverage, and employees. We're an organization that's going places. Be part of a team that cares about you, be part of UCare.
ABOUT UCAREAt UCare, we deliver high-quality health coverage and services to help members of all ages maintain and improve their health. It's a big job that takes innovative ideas, strategic partnerships, and a commitment to doing the right thing. Above all, it takes a compassionate team that is dedicated to making a real difference in the lives of our members and our communities. WORKING AT UCAREWorking at UCare is more than just a career; it's a mission. A mission that defines us as professionals, unites us as an organization, and shapes how we interact with our members and each other. Our values of integrity, community, quality, flexibility, and respect permeate every aspect of our organization - from who we are and how we act, to what we do and how we do it. We owe our continued success to our employees who proudly embody our mission and values in everything they do. BEHAVIORAL HEALTH UTILIZATION REVIEW SPECIALIST - LICSW OR RN Position Description
The Behavioral Health Utilization Review Specialist's primary responsibilities are to evaluate member specific clinical information against objective, standardized criteria to determine medical necessity, appropriateness and efficiency of specific services the organization has targeted for prior authorization. Specific duties and responsibilities include:Complete the continuum of utilization review processes within the established department turnaround times. This includes: initiate and complete first level medical necessity review; issue organization determination notifications including approvals, denials, terminations, and reductions; and routing service requests to medical directors' for physician review.Review initial and concurrent requests for outpatient mental health and chemical dependency services.Performs telephonic care review for prospective, concurrent and discharge review with psychiatric and substance use treatment facilities as assigned.Provides information to members and providers regarding mental health and substance use benefits and community treatment resources.Review initial acute inpatient mental health and rehabilitation admission request and provide concurrent review for continued stay.Facilitate discharge planning with hospital and UCare or delegate case managers.Refer cases to Care Management for potential case management activities based on identified member needs or utilization specific concerns.Develop a comprehensive knowledge of member benefits for each product; understand, implement, and support the Evidence of Coverage, and follow organization policies as they relate to member benefits. Provide medical necessity review for published authorization strategies, medical policies, review criteria, review standards, and regulatory requirements in the application of the utilization review process.Understand and support the organization's provider network and contracts.
Document review activities in accordance with professional nursing and social worker established organizational standards. Provide medical necessity review of post service requests. Collaborate with claims, provider assistance center and provider relations and contracting in ad hoc provider education.Participate in cross-departmental workgroups or teams as assigned. Other projects and duties as assigned. EducationLICSW or RN with requisite experience. Current Minnesota nursing or social worker license required.
Required ExperienceLICSW candidate with experience working with state or federally funded programs with the following:3 to 5 years' experience in psychiatric and/or substance abuse treatment. Experience in settings that include: Acute hospital inpatient, residential facilities, partial, and/or outpatient treatment and care management services in a behavioral health care management organization preferred.
RN candidate with experience working with state or federally funded programs and one of the following:3 years as staff or charge nurse in an acute hospital setting, behavioral health with adult or adolescents. 3 years as staff or charge nurse in hospital chemical dependency treatment setting or chemical dependency residential facility, working with adults or adolescents3 years as staff or charge nurse in children's residential setting 3-5 years as staff nurse or lead nurse in a mental health outpatient clinic/ACT/Mobile CrisisPreferred ExperienceLICSW or RN candidate with 2 years' experience in utilization review and/or case management. Knowledge of utilization review standards and experience working with state and federally funded programs. Experience in an HMO or MCO highly desirable. Experience working with children and adolescents with emotional disturbance and substance use disorders.
THE UCARE DIFFERENCEUCare is proud to be a recognized Star Tribune Top Workplace for the 8th consecutive year. As a part of our collaborative team, you'll experience the rewards that come with helping others and seeing the positive results of your hard work. We value and respect each individual's ideas and contributions, and give you the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, a myriad of volunteer activities, and a number of other rewards. If you're looking for a welcoming environment that celebrates what you have to offer, helps you build on your strengths, and gives you the opportunity to truly make a difference, we invite you to apply. As an Equal Opportunity/Affirmative Action Employer, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.
Enter a highly collaborative environment where people are truly engaged, and feedback is valued. You'll enjoy a competitive salary and benefits, as well as a host of other perks, including a nationally recognized wellness program, and a bright, open, award-winning office space in Northeast Minneapolis just minutes from major freeways and retail centers.
At UCare, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.