Utilization Review Specialist (BH) - RN/LP/LICSW
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 UCARE Working 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. UTILIZATION REVIEW SPECIALIST (BH) - RN/LP/LICSW Position Description This position is responsible 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. This position will also coordinate behavioral and social services across the continuum of care to assist members as they work to address their complex health conditions and social service needs. Work directly with members to engage, assess, develop, implement, coordinate, monitor and evaluate care plans for identified needs. Refer as needed and collaborate with providers, county and community agencies to coordinate the provision of services for UCare members. ·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 the behavioral health medical director for physician review. ·Provide consistent and sound first level medical necessity review for published authorization strategies, medical policies, review criteria, review standards, and regulatory requirements in the application of the utilization review process. ·Review initial and concurrent requests for inpatient and residential admissions and continued stay. Facilitate discharge planning with hospital and UCare or delegate case managers. ·Adhere and understand the interplay regulatory requirements and policies as it relates to behavioral health services and utilization review. Apply, interpret and communicate policies, procedures, clinical guidelines, medical policy, regulations and standards. ·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. ·Meet productivity and quality measures as determined by the department. ·Provide telephonic case management for members with complex medical and behavioral health conditions. ·Conduct assessments to identify individual needs including addressing social determinant of health needs and actively linking members to appropriate resources available in their community. ·Develop and maintain 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. ·Understand and support the organization's provider network and contracts. ·Document review activities in accordance with professional nursing and social work established organizational standards. ·Provide medical necessity review of post service requests as necessary. ·Participate in cross-departmental workgroups or teams as assigned. ·Participate in Holiday Coverage. This includes being on-call over a holiday weekend, review incoming faxes for urgent requests, review and respond to the request, enter authorizations, respond to requests from A&G. ·Other projects and duties as assigned. Education RN, Licensed Psychologist, or LICSW with requisite experience. Current and unrestricted Minnesota license required. Required Experience RN candidate with experience working with Medicaid/Medicare populations and one of the following: •2 years in outpatient mental health or substance use treatment facility •2 years as staff in an inpatient mental health unit, crisis residential, IRTS, or crisis residential facility. •A minimum of two years direct behavioral health clinical experience. LP or LICSW candidate with experience working with Medicaid/Medicare populations with the following: •3 to 5 years' experience in psychiatric and/or substance abuse treatment. Experience in settings that include inpatient, partial, and/or outpatient treatment and care management services in a behavioral care management organization preferred. Preferred Experience RN, LP or LICSW candidate with 2 years' experience in utilization review and/or case management. Dually licensed as LADC. Knowledge of utilization review standards and experience working with state and federally funded programs. Experience in a MCO highly desirable. THE UCARE DIFFERENCE UCare is proud to be a recognized Star Tribune Top Workplace for the 9th 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.