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Clinical Utilization Management Expert II

2 months ago

Mount Laurel, New Jersey, United States Pinnacle Treatment Centers, Inc. Full time
Job Overview

Utilization Management Specialist II

*Remote Position*

*Collaborating effectively with the treatment team and insurance providers to secure treatment authorizations*

**Experience in the addiction sector along with clinical or utilization management expertise is essential**

***Compensation for this position typically ranges from $45,000 to $55,000 annually, depending on qualifications**

We provide a competitive salary, comprehensive benefits package, Paid Time Off, and opportunities for professional advancement.

Pinnacle Treatment Centers is a prominent provider in addiction treatment services, impacting the lives of over 30,000 patients daily across the nation.

Our mission is to eliminate barriers to recovery and transform lives, families, and communities through effective treatment.

Our staff is dedicated to creating a better world where individuals and communities can heal through holistic treatment approaches.

As a Utilization Management Specialist II, you will demonstrate exceptional communication and documentation skills while collaborating closely with insurers, accreditation organizations, and other healthcare professionals. You will provide clinical insights regarding patient care needs to ensure that appropriate care is delivered in the right amount, scope, and duration. This role involves conducting utilization reviews and management for mental health and substance abuse services, identifying and addressing resource utilization discrepancies in line with established protocols and procedures. As part of the Utilization Management Team, your contributions will enhance care delivery at the system level through direct management, performance data feedback, training, and supportive consultation. This position also entails providing telephone triage support for the Admissions Department and evaluating clinical and financial information to determine eligibility for the appropriate level of care for clients.

Qualifications:

  • Master's Degree in Social Work, Psychology, Counseling, or a related Human Services field is required.
  • Must hold a valid license as a Clinical Social Worker (LCSW), Psychologist (LP), Professional Counselor (LPC), or Registered Nurse. A Licensed Clinical Drug and Alcohol Counselor (LCADC) is preferred.
  • A minimum of five years of experience in the mental health and substance abuse field is required; experience with diverse populations and direct experience in benefits and/or utilization management within a managed care environment is preferred.
  • Familiarity with current DSM (Diagnostic and Statistical Manual) and ASAM (American Society of Addiction Medicine) Medical Necessity Criteria, with the ability to make provisional diagnoses and level of care recommendations based on available information.
  • Understanding of mental health and chemical dependency treatment modalities, including inpatient, partial hospitalization, intensive outpatient programs (IOP), and outpatient services based on assessments and medical necessity criteria.
  • Ability to communicate effectively regarding benefits, medical necessity, and clinical information with provider networks.
  • Knowledge of managed care and insurance processes.
  • A valid driver's license in good standing is required, and the candidate must be insurable by the designated carrier. This role involves driving for company-related purposes.

    • Travel up to 10% may be necessary for site visits, meetings, and conferences.

Key Responsibilities:

  • Maintain a comprehensive understanding of behavioral health utilization management criteria and best practices, including care coordination with insurance companies, Medicaid, and other payor sources. Analyze and document collaboration with stakeholders to ensure consumers receive the most suitable level of care as determined by medical necessity criteria. Record and assess Utilization Management Outcomes to identify trends in stakeholder responses to consumer needs.
  • Stay updated with current provider manuals from insurers. Provide guidance to treating providers regarding insurance plan specifications for the treatment of substance abuse and mental health.
  • Propose innovative models and practices to enhance UM functions and improve cross-collaborative service efficiency and effectiveness.
  • Exemplify behaviors and initiatives that align with the mission, vision, and values of Pinnacle Treatment Centers.
  • Identify statistical, programmatic, and clinical outliers using the outlier management database and established agency protocols. Analyze outlier data, prioritize it for further review, and gather sufficient information to complete the consultation process with each affiliate, fostering collaborative relationships with providers. Utilize outlier data to pinpoint opportunities for regional development and performance enhancement. Document all data collected and analyses conducted during the review process. Collaborate with relevant providers to develop action plans addressing outliers as needed, following established agency protocols. Provide or arrange onsite reviews/consultations for unresolved outlier management issues and deliver final recommendations based on site review outcomes.
  • Supply utilization data for performance improvement and regional development initiatives.
  • Identify quality concerns related to programs, specific practitioners, or consumers, and notify the provider and relevant oversight committees as necessary.
  • Review updated clinical information from behavioral health companies promptly for utilization management certification, continued stay, and transition of care.
  • Execute daily utilization management functions at designated Recovery Works/Pinnacle locations and take appropriate actions when necessary. Maintain close communication with facility treatment teams and ensure accountability in informing leadership of any issues related to complete, accurate, and timely documentation.
  • Process appeals with managed care companies, ensuring that submitted documentation is complete, accurate, and timely.
  • Participate in multidisciplinary team and Flash meetings to discuss current clinical statuses and maintain consistency in documented issues within the Electronic Medical Record.
  • Assist with case management and transition of care responsibilities as assigned.
  • Maintain tracking mechanisms, including database administration and file management for recordkeeping and information retrieval as directed.
  • Provide administrative and clerical support to designated Clinical, Medical, and Revenue Cycle Management departments.
  • Prepare presentations, special reports, correspondence, and documentation of meetings.
  • Utilize clinical supervision and consultation appropriately to ensure work remains within the scope of practice.
  • Uphold the confidentiality of consumer and other sensitive information.
  • Perform other duties as assigned.

Benefits:

  • 18 days of Paid Time Off (PTO)
  • 401k plan with company matching
  • Company-sponsored ongoing training and certification opportunities.
  • 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 available through Capella University.

Be part of our mission to transform lives.

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