This position is the point person for all utilization activities for assigned members. As part of an interdisciplinary team, this position reviews and authorizes behavioral health and substance abuse services in inpatient, residential and outpatient settings using approved medical necessity criteria. Monitors care to ensure treatment is appropriate and effective. This position assesses the members plan of care and develops, implements, monitors and documents the utilization of resources and progress of the member through their care, facilitating options and services to meet the members health care needs. This position provides telephonic or electronic document review. This position engages internal and external resources to ensure members receive appropriate care plan and discharge planning services. This position monitors for quality of care concerns. Will staff regularly with medical directors. Within the scope of their position and licensure, this position will provide education and recommend alternative care plans for treatment not meeting medical necessity criteria. This position is accountable for the quality of clinical services delivered by both them and others and identifies/resolves barriers which may hinder effective care delivery to members. May conduct prior authorization, concurrent, retrospective, and appeal reviews.
Manages individual members across the health care continuum to achieve the optimal clinical, financial, operational, and satisfaction outcomes.
Acts in a leadership function with process improvement activities for populations of patients to achieve the optimal clinical, financial, operational, and satisfaction outcomes.
Evaluates the medical necessity and appropriateness of care, optimizing patient outcomes.
Establishes and promotes a collaborative relationship with physicians, other payers, and other members of the health care team. Collects and communicates pertinent, timely information to fulfill utilization and regulatory requirements.
Acts in a leadership function to collaboratively develop and manage the interdisciplinary patient discharge plan. Effectively communicates the plan across the continuum of care.
Educates internal members of the health care team on case management and managed care concepts. Facilitates integration of concepts into daily practice.
Requires masters degree in social work, counseling or related field or with independent or associate licensure.
Licensure in at least one of the following categories as required by state law: Social work, professional counseling or marriage and family. Appropriate licenses include: LCSW, LMSW, LPC, LAC, or Licensed Psychologist.
Requires a proficiency level typically achieved with three years clinical experience (i.e. counseling, care management, case management, care coordination in inpatient or outpatient levels of care). Must have a working knowledge of care management, case management, hospital and community resources. Must demonstrate critical thinking skills, problem-solving abilities, effective communication skills, and time management skills. Must demonstrate ability to work effectively independently and in an interdisciplinary team format.
Previous experience with behavioral health utilization management.
Additional related education and/or experience preferred.
Internal Number: 261544
About Banner Health
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.