Quality Assurance, UR & Case Management
Passion + Vision + Integrity = Excellence
Ensure consistency and the highest ethical standards across our entire organization. Our quality assurance team drives ongoing improvement by fostering an environment of support, providing technical and specialized consultative services, and inspiring ongoing excellence.
Utilization Management Specialist - Mental Health, On CallLocation: Portland, OR Job Number: 920230 Date posted: 12/02/2020
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- Benefit payment authorizations. Manage behavioral health benefits by providing medical necessity determinations. Medical necessity determinations are completed by gathering the most current clinical information from the assessing/treating provider and applying the approved Kaiser Permanente medical necessity criteria to determine what can be authorized within the benefit provisions. Medical necessity criteria are used for all pre-authorization, concurrent review and post-service requests. Authorizations must be for the most clinically appropriate, least restrictive, most cost effective and within standards of care to safely treat the member.
- Member contact. Member contact may occur for a variety of reasons which can include benefit explanations, resource identification and appointment scheduling.
- Payment denials. Kaiser policies are followed for all benefit payment denials. UM coordinator is always available to explain a payment denial to providers and members.
- Consultations. Consultations are provided to internal and external providers regarding medical necessity interpretation, benefits, covered services, contracted providers and available resources that meet the clinical needs of the Kaiser member.
- Fraud and abuse. Responsibility for ensuring the appropriate expenditure of healthcare dollars in accordance with rules and regulations set forth in Kaiser policies, licensing and credentialing entities and all state and federal laws and regulations.
- Ensuring continuity of care by facilitating communication between service providers regarding treatment planning, intervention, outcomes, and recommendations.
- Care coordination. Ensuring upon discharge from higher levels of care that all members have an appropriate discharge plan within HEIDIS guidelines.
- On-call rotation as assigned to cover pre-authorizations for non-business hours.
- Minimum three (3) years of experience working directly or indirectly with individuals with mental health or chemical dependency conditions, which would include diagnosing, treating or managing.
- Minimum two (2) years of experience in utilization management and discharge planning.
- Master's degree in mental health, social work or closely related field from an accredited institution.
License, Certification, Registration
- Understanding of medical necessity criteria and its application.
- Knowledge of DSM-IV diagnoses, community standards of treatment and treatment interventions for mental health, addictions and co-occurring disorders.
- Familiarity with community resources.
- Knowledge of how behavioral health benefits work.
- Good clinical judgment in assessing the clinical needs of patients and matching those needs to the appropriate level of care.
- Demonstrated ability to develop successful interpersonal relationships and earn the respect of physicians, nurses, therapists and other personnel.
- Able to participate as a team member, but demonstrates high level of self-motivation and ability to work independently.
- Excellent oral and written communication skills.
- Excellent problem solving abilities, detail oriented, and very organized.
- Use medical criteria for UM decision-making and education with patients, providers, and community providers.
- Ability to effectively utilize computerized medical records.
- Ability to use Microsoft Office software.
- Ability to use analytical software.
- Ability to collect, analyze, and report statistically meaningful quality and utilization data.
- Excellent written and verbal communication skills; presentation skills; analytical problem-solving skills; well developed project management skills; and competent quantitative skills.
- Current, unrestricted license/certificate in state where job is assigned:
- Oregon Licensed Clinical Social Worker (LCSW) or Licensed Marriage and Family Therapist (LMFT) or Licensed Professional Counselor (LPC) or Licensed Psychologist (PhD or PsyD) or Certified Alcohol and Drug Counselor (CADC).
- Washington Licensed Independent Clinical Social Worker (LICSW) or Licensed Advanced Social Worker (LASW) or Licensed Marriage and Family Therapist (LMFT) or Licensed Mental Health Counselor (LMHC) or Licensed Psychologist (PhD or PsyD) or Chemical Dependency Professional (CDP).
- Understanding of Milliman Criteria, ASAM Criteria, and both Kaiser and community UM processes and procedures.
- Knowledge of Kaiser Permanente resources, Behavioral Health system and benefits.
- Understanding of insurance operations and applying benefits.
- Ability to apply medical necessity criteria solely on clinical relevance and not basing decisions on financial outcomes.
- Demonstrated ability to work with providers within contractual relationships and develop positive working relationships.
- Ability to issue and explain adverse benefit determinations.
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.
Learn About QA, Ur & Case Management Careers
Careers In QA, Ur & Case Management
As an organization, we are committed to delivering the same exemplary care no matter who you are, where you are, or what your needs. But how are those standards defined, measured, and assessed? That's where our quality assurance team comes in. Implementing the action plans and initiatives that will drive successful practices, you'll work across the organization to foster the necessary education, communication, and innovation that will enable us to operate as one KP — with our mission and goals in complete alignment.
Connect with a member of the Kaiser Permanente team at an upcoming career or professional event. We look forward to seeing you!