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 600,000 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.
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.
UCare offers Medicare, Medicaid, Individual and Family health plans - powered by the hardest working people in the industry. Our people powered teams de-complicate, advocate and always go the extra mile to help our members. We serve with integrity, compassion and commitment to do right by members, providers and government partners. Above all, we come to work excited to provide members a path for the best health of their lives.
WORKING AT UCARE
Working at UCare is more than 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. Employees join UCare and stay because of the opportunity to have a purpose-driven job.
Our strong culture has established UCare as a Star Tribune Top 150 Workplace for 12 consecutive years since the awards program began. It's a culture that embraces innovative ideas, strategic partnerships, and exemplary customer and provider experiences. Working at UCare is being a part of a people powered team dedicated to making a real difference in the lives of our members and communities.
UTILIZATION MANAGEMENT LIAISON - MSS
Work Location: Work from home or hybrid (in the office 3 or more days per week)
The health and safety of our employees, members, providers, and our community is our highest priority. Therefore, all new employees are expected to be fully vaccinated against COVID-19 prior to starting at UCare, subject to limited exceptions such as for a sincerely held religious belief or for medical reasons.
This position is responsible to coordinate behavioral and social services across the continuum of care to assist members as they work to address their complex behavioral health conditions and social service needs. 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. Serve as a Liaison for Claims, 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. Partner with providers and members to engage, assess, develop, implement, coordinate, monitor and evaluate clinical information to identify care management needs. Collaborate with care givers, providers, counties and community agencies to coordinate the provision of services.
• 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 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.
• Review initial, concurrent and post service requests for inpatient, residential and outpatient levels of care. Facilitate discharge planning with facilities and UCare or delegate case managers.
• Identify mental health utilization trends and assist members in receiving appropriate services for identified needs. Perform telephonic care review for prospective, concurrent and discharge review with psychiatric and substance use treatment facilities as assigned.
• Develop and maintain a comprehensive knowledge of member benefits for each product; understand, implement and support the Evidence of Coverage, and follow the organization's policies as they relate to member benefits.
• 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.
• Stay current with behavioral health community resources and service offerings.
• Provide information to members and providers regarding behavioral health benefits and community treatment resources.
• Meet productivity and quality measures as determined by the department
• Provide backup coverage for the MSS Triage Line; including answering crisis calls for members who may need triage and referral to crisis resources. Identify and refer members that would benefit from case management services.
• Serve as a liaison between the utilization management department, providers, behavioral health medical director, claims, A&G, PRC, provider assistance and customer services to resolve issues.
• 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, LP, LPCC, LMFT or LICSW with requisite experience. Current and unrestricted Minnesota license required.
RN: Two years direct behavioral health clinical experience. Experience working with Medicaid/Medicare populations and two years in outpatient mental health or substance use treatment facility or two years as staff in an inpatient mental health unit, crisis residential, IRTS, or crisis residential facility.
LP, LPCC, LMFT or LICSW. Three years' experience in psychiatric and/or substance abuse treatment. Experience working with Medicaid/Medicare populations.
Experience in utilization management and/or case management. Dually licensed as LADC. Knowledge of utilization management standards and experience working with state and federally funded programs. Experience in a MCO. Experience in settings that include inpatient, partial, and/or outpatient treatment and care management services in a behavioral care management organization.
THE UCARE DIFFERENCE
The UCare difference is our people power - employees actively working on the behalf of our members to get them access to the health care they need. We value and respect each individual's ideas and contributions, and provide the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, and a myriad of volunteer activities. If you're looking for an inclusive environment that celebrates your people power, 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.
JOB POST DATE: 02/17/2022