Care Management Coordinator Behavioral Health (UM) - Remote (PA/NJ/DE)

Independence Blue Cross; Philadelphia (Philadelphia County); Remote; USD 60,000 - 80,000; Full time

Job summary

A healthcare organization is seeking a fully remote Behavioral Health Care Management Coordinator to evaluate members' behavioral health conditions. The candidate will utilize medical knowledge to make case determinations and ensure regulatory compliance. Ideal candidates should have at least three years of behavioral health clinical experience and relevant licenses. This role offers flexibility in work location within the Tri-State Area.

Qualifications

• Minimum of three years of Behavioral Health clinical experience in a hospital or other health care setting.
• Prior Behavioral Health utilization management experience is desirable.
• Medical Management/precertification experience preferred.

Responsibilities

• Evaluate member’s BH condition through medical records review.
• Interact with providers to obtain additional BH information.
• Provide information regarding BH condition to the Medical Director.

Skills

Communication skills

Problem solving

Interpersonal skills

Education

LCSW, LSW, LMFT or LPC

Active PA Licensed RN, BSN Preferred

Tools

Microsoft Word

Microsoft Outlook

Microsoft Excel

SharePoint

Adobe programs

Job description

Overview

The Behavioral Health (BH) Care Management Coordinator primary responsibility is to evaluate a member’s BH condition through the review of medical records (including medical history and treatment records) to determine the medical necessity for patient’s services based on advanced knowledge and independent analysis of those medical records and application of appropriate medical necessity criteria. If necessary, the BH Care Management Coordinator directly interacts with providers to obtain additional BH information. The BH Care Management Coordinator has the authority to commit the company financially by independently authorizing services determined to be medically necessary based on their personal review. For cases that do not meet established criteria, the BH Care Management Coordinator provides relevant information regarding the member’s BH condition to the Medical Director for further review and evaluation. The BH Care Management Coordinator has the authority to approve but cannot deny care for patients. The BH Care Management Coordinator is also responsible for maintaining regulatory compliance with federal, state and accreditation regulations. Additionally, the BH Care Management Coordinator acts as a patient advocate and a resource for members when accessing and navigating the behavioral health care system.

Key Responsibilities

• Applies critical thinking and judgement skills based on advanced medical knowledge to cases utilizing specified resources and guidelines to make case determinations. Utilizes resources such as InterQual, American Society of Addiction Medicine criteria (ASAM), Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan.
• Utilizes the behavioral health criteria of InterQual, ASAM and/or Medical Policy to establish the need for inpatient, continued stay and length of stay, procedures and ancillary services.
• Note: InterQual - It is the policy of the Medical Affairs Utilization Management (UM) Department to use InterQual (IQ) criteria for the case review process when required. IQ criteria are objective clinical statements that assist in determining the medical appropriateness of a proposed intervention which is a combination of evidence-based standards of care, current practices, and consensus from licensed specialists and/or primary care physicians. IQ criteria are used as a screening tool to support a clinical rationale for decision making.
• Contacts servicing providers regarding treatment plans/plan of care and clarifies medical need for services.
• Reviews treatment plans/plan of care with provider for requested services/procedures, inpatient admissions or continued stay, clarifying behavioral health information with provider if needed.
• Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Director for further evaluation/determination.
• Performs early identification of members to evaluate discharge planning needs.
• Collaborates with case management staff or physician to determine alternative setting and provide support to facilitate discharge to the most appropriate setting.
• Reports potential utilization issues or trends to designated manager and recommendations for improvement.
• Appropriately refers cases to the Quality Management Department and/or Care Management and Coordination Manager when indicated to address delays in care.
• Appropriately refers cases to Case and Disease Management.
• Ensures requests are covered within the member’s benefit plan.
• Ensures utilization decisions are compliant with state, federal and accreditation regulations.
• Meets or exceeds regulatory turnaround time and departmental productivity goals when processing referral/authorization requests.
• Ensures that all key functions are documented in accordance with Care Management Coordination Policy.
• Maintains the integrity of the system information by timely, accurate data entry.
• Performs additional duties as assigned.

Education / Licenses

Qualifications

LCSW, LSW, LMFT or LPC or Active PA Licensed RN, BSN Preferred

Experience

Minimum of three (3) years of Behavioral Health clinical experience in a hospital or other health care setting. Prior Behavioral Health utilization management experience is desirable. Medical Management/precertification Experience Preferred.

Knowledge & Skills

• Exceptional communication, problem solving, and interpersonal skills.
• Action oriented with strong ability to set priorities and obtain results.
• Team Player - builds team spirit and interdepartmental rapport, using effective problem solving and motivational strategy.
• Open to change, comfortable with new ideas and methods; creates and acts on new opportunities; is flexible and adaptable.
• Embrace the diversity of our workforce and show respect for our colleagues internally and externally.
• Excellent organizational planning and prioritizing skills.
• Ability to effectively utilize time management.
• Oriented in current trends of medical practice.
• Proficiency utilizing Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs. Ability to learn new systems as technology advances.

Work Arrangement

Fully Remote
This role is designated as fully remote. The incumbent will not be required to report to a physical office location to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.