BH Utilization Management Clinician (LCSW, LMSW) - Fully Remote

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The Behavioral Health Utilization Management (BH UM) Clinician is responsible for conducting utilization and quality management activities in accordance with New York State and MetroPlusHealth Utilization Management policies and procedures.  The position responsibilities include the management of medical costs through timely prospective, concurrent, and retrospective review activities.

Duties & Responsibilities

Performs telephonic review for inpatient and outpatient services using InterQual with Secondary Dimensions & LOCADTR and OMH Criteria Sets

• Contributes to UM program goals and objectives in containing health care costs and maintains a high-quality medical delivery system through departmental UM procedures
• Collects all pertinent clinical information and documents within CareConnect
• Promotes alternative care programs and research available options including costs and appropriateness of patient placement in collaboration with health plan members
• Communicates directly with Physician providers / designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services
• Communicates with Medical Director regarding all inpatient cases and outpatient / ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues
• Recommends, coordinates, and educates providers regarding alternative care options
• Educate providers on medication and treatment compliance while also promoting the use of Long Acting Injectables
• Enlist existing provider network in promoting first episode psychosis treatment.
• Educate providers to alternate treatment services being promoted by Health + Hospitals in lieu of Inpatient Detox
• Attends and prepares for bi-weekly Interdisciplinary Care Team (ICT) meetings which will feature newly enrolled, frequently admitted, high utilizing at risk CORE and HARP members
• Evaluate housing needs-Collaborating timely with MetroPlus Health internal housing team for supportive assistance
• Maintains an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital discharge planning staff
• Identifies potentially catastrophic and high-risk cases for case management referral
• Identifies and communicates all potential quality of care concerns to the BH UM Clinician Team Lead in a timely manner
• Contributes to MetroPlusHealth corporate goals through ongoing active team participation, offering input and assistance with development and delivery of education and trainings.
• Performs other appropriate UM Behavioral Health duties and participates in other special projects as assigned, including, but not limited to, monthly audit review and preparation, quality improvement, community health education, facility / provider relations and marketing activities.
• Support Coverage for Retrospective Reviews and BH UM Appeals as needed

Minimum Qualifications

Master’s Degree required

Licensure and / or Certification Required :

Professional Competencies :