Clinical Utilization Manager II

2 weeks ago

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

Utilization Management Specialist II

*Remote Position*

*Collaborating effectively with treatment teams and insurance providers to secure treatment authorizations*

**Candidates must possess experience in the addiction treatment sector alongside clinical or utilization management expertise**

***The compensation for this position typically ranges from $45,000 to $55,000 annually, depending on qualifications and experience**

Pinnacle Treatment Centers is a leading organization in addiction recovery services, providing care to 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.

We believe in creating a better world where individuals and communities can heal through comprehensive care.

As a Utilization Management Specialist II, you will demonstrate exceptional communication and documentation skills while collaborating closely with insurers, accrediting organizations, and healthcare providers. You will provide clinical insights regarding patient care needs to ensure appropriate treatment is delivered in the right amount, scope, and duration. This role includes conducting utilization reviews and management for mental health and substance abuse services, identifying and resolving resource utilization discrepancies in line with established protocols and policies.

Key Responsibilities:

  • Maintain a thorough understanding of behavioral health utilization management criteria and best practices, ensuring coordination of care with insurance companies and other payors.
  • Analyze and document collaboration with stakeholders to guarantee that consumers receive the most suitable level of care based on medical necessity.
  • Stay updated with current provider manuals from insurers and communicate relevant information to treating providers regarding insurance specifications for substance abuse and mental health treatment.
  • Propose innovative models and practices to enhance utilization management functions and improve service efficiency.
  • Identify statistical and clinical outliers using established protocols, analyze data, and collaborate with providers to develop action plans for improvement.
  • Provide utilization data for performance enhancement and regional development.
  • Monitor quality concerns related to programs and notify relevant parties as necessary.
  • Perform daily utilization management tasks at designated locations, ensuring accurate and timely documentation.
  • Process appeals with managed care organizations, ensuring thorough and precise documentation.
  • Participate in multidisciplinary team meetings to maintain consistency in clinical documentation.
  • Assist with case management and transition of care responsibilities as assigned.
  • Maintain tracking systems for recordkeeping and information retrieval.
  • Provide administrative support to Clinical, Medical, and Revenue Cycle Management departments.
  • Prepare reports, presentations, and documentation of meetings.
  • Ensure confidentiality of consumer information at all times.
  • Other duties as assigned.

Qualifications:

  • Master's Degree in Social Work, Psychology, Counseling, or a related field is required.
  • Licensure as a Clinical Social Worker (LCSW), Psychologist (LP), Professional Counselor (LPC), or Registered Nurse is required; LCADC is preferred.
  • A minimum of five years of experience in mental health and substance abuse is required, with experience in managed care settings preferred.
  • Familiarity with DSM and ASAM criteria is essential for making informed clinical decisions.
  • Knowledge of various treatment modalities based on assessments and medical necessity criteria.
  • Ability to communicate effectively regarding benefits and clinical information with provider networks.
  • Must possess a valid driver's license and be insurable for company-related travel, which may require up to 10% travel for site visits and meetings.

Benefits:

  • 18 days of Paid Time Off (PTO)
  • 401k plan with company matching
  • Ongoing training and certification opportunities sponsored by the company.
  • Comprehensive benefits package including medical, dental, vision, and disability insurance.
  • Loan repayment program for Substance Use Disorder Treatment and Recovery.
  • Discounted tuition and scholarships available through Capella University.

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