Benefits Coordinator, Managed Care - Contract

Macomb County Community Mental Health; Clinton Charter Township (MI); On-site; USD 60,000 - 75,000; Full time

Job summary

Macomb County Community Mental Health seeks a clinical professional to coordinate referrals, determine eligibility, review service requests, and ensure medically necessary authorizations align with benefits and organizational policies.

The role involves liaison work with providers, completing required documentation, and contributing to program improvement while complying with Michigan regulations.

Qualifications

• Master’s degree in social work, Counseling, Psychology or Doctorate in Psychology or a directly related mental health field from an accredited college or university.
• Two (2) years of clinical experience working in a mental health setting.
• One (1) or more years' experience in utilization management.
• One (1) or more years’ experience with an electronic medical record system from Peter Chang Enterprises (PCE).
• Licensed Master Social Worker (LMSW), LLMSW, Licensed Professional Counselor (LPC), LLPC, Temporary Limited Licensed Psychologist (TLLP), Limited License Psychologist (LLP), or Licensed Psychologist (LP).
• Possession of a valid Michigan driver's license and operable automobile for authorized travel.

Responsibilities

• Review member benefit plans and authorization requests to determine coverage eligibility, benefit availability.
• Conduct brief reviews, document findings, and ensure authorization requests are processed per regulations and policies.
• Collaborate with providers to obtain information for benefit verification and authorization processing.
• Complete case documentation following MCCMH policies and procedures.
• Identify trends and opportunities for service and process improvement.

Education

Master’s degree in social work, Counseling, Psychology or Doctorate in Psychology or a directly related mental health field

Two (2) years of clinical experience working in a mental health setting

One (1) or more years' experience in utilization management

One (1) or more years’ experience with an electronic medical record system from Peter Chang Enterprises (PCE)

Licensed Master Social Worker (LMSW), LLMSW, LPC, LLPC, TLLP, LLP, or LP

Valid Michigan driver's license

Ability to meet privileging and credentialing guidelines

LMSW/LPC/LP as preferred licenses

Job description

Under direction, provides linkage and referrals to individuals seeking Macomb County Community Mental Health (MCCMH) services; provides indirect clinical services; determines eligibility, medical necessity of services authorized; reviews requests for services from a utilization management perspective; maintains clinical and administrative records; coordinates, consults, and provides liaison work with other agencies and systems; implements program goals and activities. Performs other duties as assigned.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

Review member benefit plans and authorization requests to determine coverage eligibility, benefit availability, and accurate application of coverage provisions.

Conduct brief reviews, document findings, and ensure authorization requests are processed in accordance with regulatory requirements, contractual obligations, and organizational policies.

Partner with internal departments to evaluate funding sources, resource availability, and program eligibility for requested services

Ensure persons served receive medically necessary service authorizations within benefit and organizational guidelines.

Serve as a key resource for providers, person served, and internal departments regarding benefit coverage and authorization requirements.

Conduct benefit and eligibility reviews for prior authorization requests.

Collaborate with providers to obtain necessary information for benefit verification and authorization processing.

Apply authorization guidelines, benefit policies, and organizational policies consistently.

Explain coverage determinations and authorization processes in a professional and customer-focused manner.

Research discrepancies in benefits and resolve issues in collaboration with internal departments.

Complete case documentation following MCCMH policies and procedures.

Complete and maintain Community Mental Health and Department of Mental Health statistical and activity reports.

Identify trends and opportunities for service and process improvement.

QUALIFICATIONS

Required Education and Experience

• Master’s degree in social work, Counseling, Psychology or Doctorate in Psychology or a directly related mental health field from an accredited college or university
• Two (2) years of clinical experience working in a mental health setting

Preferred Education and Experience

• One (1) or more years' experience in utilization management
• One (1) or more years’ experience with an electronic medical record system from Peter Chang Enterprises (PCE)

Required Licenses or Certifications

• Licensed Master Social Worker (LMSW), Limited Licensed Master of Social Work (LLMSW), Licensed Professional Counselor (LPC), Limited License Professional Counselor (LLPC), Temporary Limited Licensed Psychologist (TLLP), Limited License Psychologist (LLP), or Licensed Psychologist (LP)
• Possession of required state licensure appropriate to the position and the ability to meet privileging and credentialing guidelines
• Possession of a valid Michigan driver's license and operable, insured automobile for authorized travel

Preferred Licenses or Certifications

• Licensed Master Social Worker (LMSW), Licensed Professional Counselor (LPC), or Licensed Psychologist (LP)

COMPETENCIES FOR SUCCESSFUL PERFORMANCE OF JOB DUTIES

Knowledge of:

• Working knowledge of non-Medicaid funding in the PIHP/CMHSP environment.
• Knowledge of Macomb County Provider Network
• Understanding of waitlist requirements per the Michigan Mental Health Code.
• Resources within MCCMH and outside of Macomb County Community Mental Health
• Michigan Mental Health Code and 401 criteria
• Mental illness, serious emotional disturbance, and developmental disabilities
• Techniques to de-escalate/interact in potentially dangerous situations
• Knowledge of applicable computer applications.
• Knowledge of third-party insurance procedures and requirements.
• Knowledge of Medicare insurance procedures and requirements.

Skill in:

• Using good professional judgment and initiative.
• Providing excellent and timely customer service
• Performing a variety of duties, often changing from one task to another

Ability to:

• Collaborative: Approaches all situations with teamwork and a solution-focused mindset, demonstrated through active participation in meetings, volunteering to assist teammates and other departments as appropriate. Examples include participation in internal and external committees, subcommittees, process-improvement groups, and other multi-organizational initiatives.
• Accountable: Takes ownership and empowers others to do the same, as evidenced by identifying solutions and acting on job responsibilities and organizational objectives daily.
• Respectful: Treats people with dignity while honoring individual differences demonstrated through use of positive and encouraging statements and/or interactions to, about, and/or with colleagues and persons served; evidenced by supervisor observation, feedback from other department staff, and leadership.
• Effectively speak, write, and understand English.
• Effectively speaking, writing, and understanding a language other than English is preferred.
• Understand and carry out oral and/or written instructions.
• Accurately organize and maintain paper documents and electronic files.
• Maintain the confidentiality of information.
• Work independently

GENERAL REQUIREMENTS AND DISCLAIMERS

Complies with P.A. 390, as amended, known as the State’s Emergency Management Act and the County’s Emergency Management resolution as well as all related plans, policies and procedures covered by those statutes. The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by employees in this job. Employees may be requested to perform job-related tasks other than those specifically presented in this description.

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment amongst other possible accommodations.

GRANT OR EXTERNALLY FUNDED POSITION –This position will continue only if sufficient grant or external funds are provided.