Current jobs related to Clinical UM - Mount Laurel - Pinnacle Treatment Centers, Inc.

Clinical UM & Appeals Specialist II

We offer competitive salary, full benefits package, Paid Time Off, and opportunities for professional growth. 

Pinnacle Treatment Centers is a growing leader in addiction treatment services. We provide care across the nation touching the lives of more than 35,000 patients daily.  

Our mission is to remove all barriers to recovery and transform individual, families, and communities with treatment that works.   

Our employees believe we are creating a better world where lives and communities are made whole again through comprehensive treatment.  

As a Clinical UM & Appeals Specialist II, you will perform advanced-level work related to utilization management and clinical denial management. This is a highly skilled position that requires the knowledge and understanding of medical necessity criteria for all levels of care. You must have the ability to determine the clinical severity of illness/intensity of service criteria for individuals receiving care in any assigned level of care within the organization, and the aptitude to communicate identified concerns with providers to ensure patients receive proper care in the right amount, scope, and duration.

Requirements:

• Master’s degree in social work, Psychology, Counseling, or related Human Services field is required.
• Licensed Clinical Social Worker (LCSW), Licensed Psychologist (LP), Licensed Professional Counselor (LPC), or Registered Nurse is required. A Licensed Social Worker (LSW) or Licensed Associate Counselor (LAC) with related equivalent experience may be considered.
• Familiarity with Medical Necessity Criteria is required.
• Experience in DSM Diagnostic and ASAM Medical Necessity Criteria and demonstrate competence in making mental health and chemical dependency provisional diagnoses and level of care recommendations with available information.
• Experience working in mental health and chemical dependency inpatient, partial hospital, intensive outpatient program (IOP) and outpatient modalities based on an assessment and medical necessity criteria.
• Relate and discuss benefits, medical necessity, and clinical information with provider network.
• Able to track necessary information and organize it into accurate and timely reports.
• Travel Required: Must possess a current valid driver’s license in good standing in the state of employment and be insurable by the designated carrier. This role is required to drive for company purposes. Travel up to (10%) may be required to attend site visits with providers, meetings, and conferences.

Preferred education and experience

• Licensed Clinical Drug and Alcohol Counselor (LCADC).
• Knowledge and background with managed care and insurance.
• Experience working in the field of substance use and/or mental health, experience with all target populations and direct experience performing benefits and/or utilization management in a managed care setting.

Responsibilities:

• Maintain prominent level knowledge of behavioral health utilization management criteria and best practices including coordination of care with insurance companies, Medicaid, and other payor sources. Provides, analyzes, and documents collaboration with stakeholders to ensure patients receive the most appropriate level of care as designated by medical necessity criteria. Records and analyzes Utilization Management Outcomes to identify trends in stakeholder response to the patient’s needs.
• Recommend new models and innovative practices to improve UM functions and cross-collaborative service efficiencies and effectiveness.
• Identify statistical, programmatic, and clinical outliers utilizing the outlier management database and established agency protocols.
• Analyze the outlier data, prioritize the data for further analysis and review, and collect sufficient data to complete the consultation process with each affiliate in a manner that seeks to build collaborative relationships with each provider. Analyze the outlier data to identify opportunities for regional development and performance improvement. Fully documents all data collected and all analyses conducted during the review process. Develop action plans jointly with relevant providers to address the outliers when required, based on established agency protocols. Provide or arrange onsite reviews/consultation for unresolved outlier management issues and subsequently provide final recommendations based on the outcome of the site review.
• Provide utilization data for performance improvement and regional development purposes.
• Review with behavioral health companies updated clinical information on a timely basis for the purpose of utilization management certification, continued stay, and transition of care.
• Perform utilization management functions at designated Pinnacle location(s) and take appropriate action when necessary.
• Communicate with the facility treatment teams and accountability to inform leadership of any issues pertaining to complete, accurate, timely documentation.
• Review all appeal records for completion, categorization, level of appeal, payor time frames, and special requirements for initiating appeals.
• Maintain a clinical appeal process for denials assuring that proper documentation is provided to support appeals/requests for coverage of unauthorized days.
• Make a preliminary determination whether denial can be overturned and if initial or secondary appeals should be submitted.
• Utilize medical necessity criteria (i.e., ASAM, InterQual, MCG) to analyze clinical documentation to create compelling arguments for the payor to authorize uncovered treatment.
• Research and submit detailed, customized appeals to payers based on review of medical records and in accordance with Medicare, Medicaid, and third-party guidelines as well as Pinnacle Treatment Center policies and procedures.
• Fully document all activities related to the denial management/appeals process (e.g., consults, trainings, payor correspondence, appeal dispositions, claim payments).
• Maintain tracking mechanisms including database administration and file administration for recordkeeping and information retrieval as directed.
• Remain current on payor authorization and appeal processes (i.e., timeframes, required forms, documentation/submission requirements).
• Review payor communications (e.g., provider manuals, policies, announcements) and identify risk for lost reimbursement related to medical policies and authorization requirements; escalate potential issues to applicable departments and leadership as appropriate.
• Identify and use available payor portals in efforts to improve the appeal submission process and decrease appeal disposition timeframes.
• Serve as a resource to staff, and provide training as needed, regarding post service reviews, peer reviews, and navigation of other levels of appeal.
• Identify, document, and communicate denial patterns and recommend process improvements or system edits to all applicable stakeholders, to reduce or eliminate future denials.
• Identify quality concerns related to programs, specific practitioners, or patients, and notify the provider and relevant oversight committees (if relevant) of them.
• Participate in meetings as needed (e.g., Multidisciplinary Team, Facility Flash, Clinical Directors) to provide denial/appeal data in efforts to identify opportunities for improvements in denial performance.
• Maintain absolute file integrity with regards to content, location, and confidentiality
• Other duties as assigned.

Benefits:

• 18 days PTO (Paid Time Off)
• 401k with company match
• Company sponsored ongoing training and certification opportunities.
  • Full comprehensive benefits package including medical, dental, vision, short term disability, long term disability and accident insurance.
• Substance Use Disorder Treatment and Recovery Loan Repayment Program (STAR LRP)
• Discounted tuition and scholarships through Capella University

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