Licensed Behavioral Health Quality and Utilization Review Consultant I

In addition to the responsibilities listed below, this position is also responsible for reviewing services (e.g., mental health assessments, treatments, crisis interventions) and documentation to ensure quality, accuracy, and completeness; conducting a clinical review of moderately complex treatment plans and follow-up care to ensure appropriateness and alignment with best practices and internal and external guidelines; leveraging guidelines and tools to provide direction on appropriate behavioral health interventions and care plans as well as documentation of care provided; reviewing intakes, follow-up visits, and/or progress updates to ensure each entry has a complete and accurate assessment of mental health risk (e.g., suicide, abuse) and that appropriate procedures and processes are followed; educating physicians and allied health professionals to ensure understanding of regulatory requirements and align on behavioral health care plans; and independently conducting quality management studies through data collection, analysis, and synthesis to identify areas for program improvements and assess risks.

• Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome.


• Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.


• Ensures quality of care by: using advanced knowledge to review moderately complex patient assessments, care, and interventions for completeness and accuracy; prioritizing patient experience during internal and external care transitions by proactively anticipating and identifying barriers; documenting the progression of treatment plans and conducting moderately complex chart reviews; contributing critical updates during multi-disciplinary clinical consultation meetings to discuss patient treatment; and coordinating patient care needs (e.g., coordinating transfers, planning discharges, making community service referrals, reviewing and/or obtaining authorizations) as they move across the continuum of care.


• Manages patient data and records by: compiling and reporting patient information and data (e.g., length of stay, services provided, cost) and facilitating interventions as necessary; and conducting quality management studies and/or audits through data collection, data input, and report development and collaborating with stakeholders to improve future practices.


• Coordinates the care of a moderate caseload of patients by: collaborating with treating clinician to review and ensure quality of patient treatment plans; advising, guiding, and/or coordinating services to improve care coordination based on quality principles; using advanced knowledge to recommend patient referrals for moderately complex cases; developing and maintaining case management policies and procedures to ensure optimal and appropriate member utilization and engagement of services; and solving problems concerning patient treatment plans and follow-up appointment documentation.


• Ensures member compliance with policies and procedures by: solving compliance failures to promote patient care and avoid liability concerns; applying local, state, and federal standards, regulations, credentialing organizations requirements, health plan benefits, policies, and procedures when working with patients, physicians, medical office staff, contact providers, and outside agencies; and leading efforts to support the survey readiness program at contracted facilities and/or medical centers to maintain compliance with regulatory standards.


• Collaborates with stakeholders to facilitate care by: cultivating relationships with external providers, medical center physicians, and/or other staff to solve patient treatment problems collaboratively and ensure contract compliance; and establishing relationships with outside contractors as well as serving as a liaison on contracting consultation including informing and advising on the organizations levels of care and referral process.