Utilization Review Liaison - Behavioral Health

Minneapolis, Minnesota
Jan 16, 2019
Jan 24, 2019
Employment Status
Full Time

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.


At 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 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.


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 and post service reviews.  Serve as a Liaison for CCO, Medical Directors, A&G, PRC, Customer Service, and Provider Assistance.  Conduct clinical review and evaluation of provider appeals, reconsiderations/disputes using clinical judgment, independent analysis and detailed knowledge of medical policies, clinical guidelines and benefit plans to determine the appropriateness of care provided.

·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 directors 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.

·Collaborate with and refer cases to Care Management for potential case management activities based on identified member needs or utilization specific concerns.

·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.

·Provide first level medical necessity review for post service requests through monitoring, processing and reporting of MACESS aging to ensure compliance with departmental service level agreement.

·Serve as a liaison between the utilization review department, providers, behavioral health medical director, CCO, A&G, PRC, provider assistance and customer services to resolve issues.

·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.

·Ensure decision rational reflects accurate regulatory required provider and comprehensive member notifications language. Efficiently and accurately communicate coverage decisions to members, providers and medical groups within regulatory timelines.

·Expert resolution skills by responding, resolving or de-escalating member and provider inquiries regarding authorizations, authorization process, coverage determinations, benefit exceptions and member reimbursement.

·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.


RN or LICSW with requisite experience.  Current and unrestricted Minnesota nursing or social work license required.

Required Experience

RN candidate with experience working with state or federally funded programs and one of the following:

Three years as staff or charge nurse in hospital, preferably med/surg adults; or two years as staff or charge nurse in hospital and two years long term care experience in Medicare nurse role; or five years long term care experience and two years home care nursing; or two years as staff or charge nurse in hospital and two years home care nursing.  A minimum of two years direct behavioral health clinical experience.

LICSW candidate with experience working with state or federally funded programs with the following:

3 to 5 years' experience in psychiatric and/or substance use disorder treatment. Experience in settings that include inpatient, partial, and/or outpatient treatment and care management services in a behavioral care management organization preferred

The RN or LICSW candidate will have two years of clinical experience, working with Medicare, Medicaid and Commercial managed care.

Preferred Experience

Two years of utilization management experience.  Experience using standardized clinical guidelines, InterQual experience.


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.

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