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013650 CCA-Auth & Utilization Mgmt

Position Summary:

The Sr Clinician, Behavioral Health Utilization Review will review behavioral health and substance use admissions for medical necessity and appropriate levels of care and assist with transition of care planning and coordination when a Commonwealth Care Alliance clinician is not already involved. Work with ESPs to ensure appropriate and timely placement for inpatient admission.

Supervision Exercised:

+ None

Essential Duties and Responsibilities:

+ Conduct telephonic preadmission, concurrent and retrospective clinical review of focused behavioral health and substance use inpatient admissions through application of evidence-based medical necessity criteria, CCA policies and procedures, and regulatory and legislative requirements.

+ Focus on effective and appropriate utilization of alternative levels of care and collaborate with ICT and Inpatient staff to explore all diversionary services and step-down placements to ensure member receives appropriate level of care in least restrictive environment.

+ Determine medical necessity and level of care based on the consistent application of decision support tools, and communicate decisions to facility, providers, treatment team and member.

+ Interact with facility staff, primary care teams and other treatment team members to evaluate transition of care needs and prepare member and family for discharge.

+ Coordinate authorization and/or delivery of post-acute services and coordinate follow-up care to ensure plans for continuity of care and adherence to quality standards.

+ Understand and appropriately manage member’s benefits to maximize health care quality.

+ Interface with Primary/Interdisciplinary Care Team including Care Coordinator, Care Manager, and others to consult on clinical decision making, optimize member care and ensure safe and effective hand-offs and transitions.

+ Receive, screen, triage, and respond to telephone calls from members requiring Behavioral Health clinical direction and advice

+ Participate in back-up on-call rotation

+ Position may require the ability to travel to facilities within Massachusetts.

Working Conditions:

+ Position is office based or remote.

+ Position requires periodic travel for site visits, staff meetings, and training

Required Education:

+ Master’s degree or higher in health-related field required

Desired Education:

+ LICSW is preferred

Required Licensing:

+ Current, valid, and unrestricted licensure in mental/behavioral health (LCSW, LPC, LMFT, or LMHC) required.

Required Experience:

+ Minimum of 3 years’ experience in psychiatric and/or substance use health care settings

Desired Experience:

+ Experience in behavioral health managed care preferred

+ Experience in behavioral health utilization review or medical necessity evaluation preferred

Required Knowledge, Skills & Abilities:

+ Demonstrated knowledge of utilization review procedures

+ Demonstrated knowledge of mental health and substance use community resources and network providers

+ Skilled in negotiation and motivational interviewing

Language(s):

+ English

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.