LOCATION: Remote - must live in North Carolina or within 40 miles of the NC border.

GENERAL STATEMENT OF JOB

The Mental Health/Substance Use (MHSU) Utilization Management (UM) Clinician provides multiple utilization review tasks, including review of Service Authorization Requests (SARs), Person-Centered Plans (PCPs)/Treatment Plans and clinically relevant documentation for authorization of clinically appropriate services. The MHSU Utilization Management Clinician works with service providers to facilitate appropriate service planning and service provision. The MHSU Utilization Management Clinician will provide other clinical reviews, and case consultations to facilitate the provisions of clinically appropriate services to members with mental health and substance use disorders.

ESSENTIAL JOB FUNCTIONS

Review Service Authorization Requests (SARs):

• Review PCPs/Treatment Plans submitted by providers with authorization requests
• Where plans do not meet established standards for medical necessity, provide feedback and request additional information from providers, including consultation and education as appropriate
• Authorize requested services meeting authorization requirements and medical necessity
• Send Educational Notifications for requests not meeting sufficient information and other administrative requirements
• Refer service requests for medical necessity determinations to a Peer Reviewer when medical necessity is not established
• Ensure complete documentation of review and determinations
• Conduct Health and Safety Reviews
• Submit pharmacy consultation documentation and document any concerns associated with the review.
• Discuss treatment progress and current clinical presentation with referring provider as needed to aid in medical necessity determination\

Facilitate Development of the Provider Network:

• Identify and document service gaps and deficiencies in access to services
• Consult with and educate providers about Vaya Health service authorization requirements, evidence based practices and other components to quality service provision
• Identify provider training needs; provide training as needed and requested or refer providers for additional training support/needs (e.g. submit investigative referrals or document quality of care concerns)
• Provide consultation to providers as requested regarding difficult and high-risk cases
• Collaborate with Vaya Health Care Management and Care Coordination staff to improve services to high risk members and those without a Clinical Home

Other duties as assigned.

KNOWLEDGE, SKILL & ABILITIES

• A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance. This will require exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts. Problem solving, negotiation, arbitration and conflict resolution skills are essential to balance the needs of both internal and external customers.
• Mastery of utilization review principles to ensure continuity of care and clinical evaluations as needed for appropriate provision of intensive, crisis services and other levels of care.
• Knowledge of prior authorization review, continued stay and discharge reviews for MH/SU services to ensure appropriate service intensity and level of care for member.
• Knowledge of documentation and clinical protocols for utilization purposes.
• Knowledge of linkage, authorization and level of care determinations, assisting providers with creative problem solving to suggest alternative approaches to care.
• Clinical knowledge of managed systems of mental health and substance use. Knowledge of managed behavioral care practices and principles in order to provide Care Management.
• Ability to collaborate with providers and other agencies.
• Clinical knowledge of mental health and substance use treatment as a basis for clinical reviews and decisions for authorization.
• Comprehensive knowledge of resources and the ability to use a personal workstation. Knowledge of database and data entry is essential.

QUALIFICATIONS & EDUCATION REQUIREMENTS

Master's degree in a Human Services field. Two years of post-degree progressive experience and practice that is relevant to the clinical area for which they will be conducting the initial clinical review. Experience in a Utilization Management environment in Behavioral Healthcare is required for this employee.

Licensure/Certification Required:

Must possess a current, active, unrestricted professional license or certification from North Carolina in a Human Services field (such as Psychology, Social Work, Counseling, Marriage and Family Therapy, Addictions, etc.).

PHYSICAL REQUIREMENTS:

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: This position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.