Supervises daily Behavioral Health Utilization Management (UM) operations and productivity including initial medical necessity review, continued stay review, discharge planning, and care coordination, and monitors individual staff caseloads and patient treatment plans to ensure delivery of timely and appropriate care. This position is responsible for assisting with staff training and auditing staff performance to ensure compliance with TriWest policies, UM related desk procedures, and accurate data entry and application of the Medical Management System. This position interacts with staff, Veterans and Veteran treatment facilities as the subject matter expert on UM program issues. This position also provides support to the non-clinical staff regarding UM related work.
o Supervises daily UM operations by overseeing clinical and non-clinical staff production, managing to production goals, auditing staff performance, coaching and developing staff.
o Ensures staff is fully-informed of changes by communicating updates, policy revisions, performance outcomes, and significant events.
o Prepares work schedules and monitors staff caseloads to ensure adequate staffing levels at all times and accurate data entry and application of the medical management systems
o Assesses staff performance, advises and counsels as necessary, and conducts annual performance evaluations.
o Participates in staff hiring and training process.
o Monitors staff to ensure adherence to established criteria, including InterQual, internally developed guidelines, decision support tools, contract requirements and TriWest policies and desk procedures.
o Provides guidance to staff and/or interacts with patients, providers and Veteran facilities on complex cases.
o Reports Potential Quality Issues (PQI).
o Implements work processes to ensure that requested case determinations and notifications meet contract compliance standards and identifies opportunities for process improvement.
o Plans, organizes and implements staff in-service training and staff development activities. Ensures department meets all training requirements.
o Assists manager with data collection and analysis of management reports.
o Develops information managing performance and assists in updating desk procedures.
o Performs other duties as assigned.
o Regular and reliable attendance required
Education & Experience
o RN or LCSW (Independently Licensed Clinical Social Worker) with current unrestricted license in appropriate state or territory of the United States
o 3+ years of clinical experience
o 2 years supervisory or leadership experience
o Managed care and operational experience in medical management systems, including referral management/prior authorization or utilization management
o Supervisory experience in an inbound call center environment
o Military healthcare or equivalent experience
o Knowledge of medical terminology specific to behavioral health
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