MH & SUDS Utilization Management Specialist-Dually Licensed

Work Location: Work from home or Hybrid (in the office 3 or more days per week)

The health and safety of our employees, members, providers, and our community is our highest priority. Therefore, all new employees are expected to be fully vaccinated against COVID-19 prior to starting at UCare, subject to limited exceptions such as for a sincerely held religious belief or for medical reasons.

Position Description

This position is responsible to coordinate mental health, substance use disorder and social services across the continuum of care to assist members as they work to address their complex mental health and substance use disorder conditions and social service needs. Evaluate member specific clinical information against standardized criteria and regulatory guidelines to determine medical necessity, appropriateness, and efficiency of specific services the organization has targeted for prior authorization and to assess for treatment progress and ongoing needs as part of a concurrent review process. Partner with providers and members to engage, assess, develop, implement, coordinate, monitor and evaluate the member's clinical status to assist with shaping of care and facilitation of a longitudinal treatment plan.

??Complete the continuum of utilization management processes within the established department turnaround times. This includes: initiation and completion of first level medical necessity review; issue organization determination notifications including approvals, denials, terminations, and reductions; routing service requests to the medical director for physician review and completing secondary SUD reviews alongside medical director. Follow all regulatory guidelines in these processes.

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??Assist members in receiving appropriate services for identified needs. Perform telephonic care review for prospective, concurrent and discharge review with mental health and substance use disorder treatment facilities as assigned. Collaborate with members, primary care providers, clinic staff and other relevant agencies to assure appropriateness of service that meets member needs and supports desired outcomes. Facilitate discharge follow up calls post hospitalization with members and verify with their providers completion of follow up appointments.

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??Provide consistent and sound first level medical necessity review for published authorization strategies, medical policies, review criteria, review standards, and regulatory requirements in the application of the utilization management process.

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??Review initial, concurrent and post service requests for inpatient, residential and outpatient levels of care. Facilitate discharge planning with facilities and members including consideration of any ongoing medical services, as well as MH and SUD services, and resources to address social determinants of health.

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??Provide support and disseminate information to colleagues regarding SUD specific policies and procedures, services, medical necessity, levels of care, and available resources and facilities.

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??Attend and act as a UCare representative at virtual meetings with DHS regarding substance use disorder services.

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??Use clinical judgement to identify service utilization trends and any concerns about delivery of quality services.

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??Adhere and understand the regulatory requirements and policies as it relates to mental health and substance use disorder services and utilization management. Apply, interpret and communicate policies, procedures, clinical guidelines, medical policy, regulations and standards.

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??Provide information to members and providers regarding mental health and substance use disorder benefits and community treatment resources.

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??Facilitate referrals to case management and other UCare programs such as disease management, wellness programs and Intensive Community Based Services to assist with the ongoing management of care needs.

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??Meet productivity and quality measures as determined by the department.

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??Document clinical activities in accordance with professional licensing board established organizational standards.

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??Provide backup coverage to the Mental Health and Substance Use Disorder Triage Line; which includes assisting members in crisis with connection to immediate emergency help and/or community resources. Use of motivational interviewing skills while working with members in crisis. Completion of a crisis assessment tool, safety plan and member follow up. Identification and referral of crisis cases to care management services as appropriate.

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??Develop and maintain a comprehensive knowledge of member benefits for each product; understand, implement, and support the Evidence of Coverage, and follow organization policies as they relate to member benefits.

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??Collaboration with providers, county staff, social workers and licensed mental health professionals regarding pre-placement and screening for Rule 5 placements.

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??Understand and support the organization's provider network and contracts.

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??Participate in Holiday Coverage. This includes being on-call over a holiday weekend, review incoming faxes for urgent requests, review and respond to the request, enter authorizations, respond to requests from A&G.

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??Other projects and duties as assigned.

Education

RN, LP, LPCC, LMFT or LICSW; dually licensed as a Licensed Alcohol and Drug Counselor (LADC). Current and unrestricted Minnesota license required.

Required Experience

RN: Three years direct mental health and substance use disorder clinical experience. Experience working with Medicaid/Medicare populations and two years in outpatient mental health or substance use treatment facility or two years as staff in an inpatient mental health unit, crisis residential, IRTS, or crisis residential facility.

LP, LPCC, LMFT or LICSW: Three years' experience in mental health and/or substance use treatment. Experience working with Medicaid/Medicare populations.

Preferred Experience

All licensures: Experience in utilization management and/or case management. Knowledge of utilization management standards and experience working with state and federally funded programs. Experience working for an MCO. Training and expertise in Motivational Interviewing skills. Experience in settings that include inpatient, partial, and/or outpatient treatment and care management services in a care management organization.