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Care and Utilization Manager, BH
2 months ago
Apex Health Solutions is seeking a highly skilled Care and Utilization Manager, BH to join our team of healthcare professionals. As a key member of our organization, you will play a critical role in improving health outcomes and reducing healthcare costs through a coordinated approach.
Key Responsibilities:- Primary Care Management: Provide comprehensive care management interventions, including screening, assessment, care planning, and implementation of interventions, to identified behavioral health/substance misuse members.
- Utilization Management: Utilize industry-accepted guidelines to determine the appropriate level of care and coverage determinations, working closely with the behavioral health medical director.
- Risk Identification: Identify members at risk for poor outcomes or experiencing poor coordination of services who would benefit from more intensive follow-up and care coordination.
- Comprehensive Assessment: Conduct thorough assessments of members' current status, considering physical, behavioral, social, and economic care needs.
- Care Planning: Coordinate comprehensive plans of care for high-risk, high-utilizing populations, collaborating with clinical staff and patients/families in the development and execution of care plans and achievement of goals.
- Proactive Outreach: Provide proactive outreach to members through telephonic, internet, or face-to-face encounters.
- Interdisciplinary Collaboration: Work seamlessly with other health management disciplines to assist members in problem-solving potential issues related to financial and psychological barriers, as well as problems with the overall system of care.
- Continuity of Care: Improve continuity of care by managing and facilitating relationships with post-acute providers, physicians, and community resources.
- Chronic Disease Management: Conduct chronic disease and self-management education and support to improve comprehension, health literacy, and adherence to established plans of care.
- Medication Management: Provide medication management support, including comprehensive medication review and adherence education.
- Stakeholder Communication: Communicate, collaborate, and cooperate with internal and external stakeholders.
- Interdepartmental Collaboration: Collaborate effectively with Utilization Management, Case Management, Population Management, Quality Management, Pharmacy, Provider Relations, and other health plan departments.
- Compliance and Integrity: Adhere to all Compliance/Program Integrity requirements and comply with HIPAA Regulations.
- Professional Development: Promote individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency.
- Education: Active Registered Nurse license in Texas or compact license.
- Skills: Knowledge of healthcare delivery, ability to work in a fast-paced environment with changing priorities, ability to work with interdisciplinary teams and others in a matrixed environment, demonstrated written and verbal communication skills, demonstrated time management and priority setting skills, demonstrated problem-solving skills, demonstrated organizational skills, demonstrated ability to converse with and collaborate with physicians and other healthcare personnel, reasoning ability to identify and define problems, collect data/information, establish facts, and draw valid conclusions, makes decisions and implements changes related to TDI and Federal regulations, ability to demonstrate knowledge of ACO initiatives and care management processes, understanding of NCQA and CMS care management guidelines preferred.
