Authorizes and reviews utilization of mental health and substance abuse services provided in inpatient, outpatient and intermediate care settings; assists with discharge planning and ambulatory follow up activity; Maintains phone coverage for Clinical Referral line on ACD system; provides member assistance with mental health and substance abuse issues, and participates in special utilization projects.  Scheduling of work hours is in accordance with business needs and may include evening and on-call responsibilities when needed.

PRIMARY RESPONSIBILITIES:

• Determines appropriate level of care related to mental health and substance abuse treatment for members based on Beacon’s medical necessity criteria
• Analyzes specific utilization problems, and plans and implements solutions that directly influence quality of care and financial liability
• Interacts with physicians and other members of the provider clinical team for discharge planning
• Performs telephonic case review for pre-admission and continuing care in psychiatric and substance treatment facilities
• Provides telephone triage, crisis intervention and emergency authorizations as assigned
• Performs concurrent reviews for inpatient care and other levels of care as allowed by scope and practice and experience
• Provides information to members and providers regarding mental health and substance abuse benefits, and community treatment resources
• Interacts with Physician Advisors to discuss clinical/authorization questions and concerns regarding specific cases
• Interacts with providers and facilities in a professional, respectful manner that facilitates the treatment process
• Authorizes treatment for medical necessity for mental health and substance abuse problems according to clinical information given by providers and internal criteria for medical necessity and appropriateness of care
• Proposes alternative plans of treatment when requests for services do not meet medical necessity criteria
• Complies with Beacon’s standards for documentation of clinical information, clinical contacts and authorization of care
• Well versed in product lines and benefit structures for all plans managed by Beacon
• Knowledgeable of all acute, diversionary and outpatient levels of care for all contracts managed by Beacon   
• Schedules outpatient appointments as necessary based on urgency and clinical need 
• Assists with NCQA, URAC and other QI initiatives
• Provides back-up coverage for After Hours Clinical Case Managers as assigned
• Other duties as assigned    

SCOPE: Non-certifications may not be issued on initial review, and always require consultation with a Physician or Psychologist Advisor

REQUIRED QUALIFICATIONS:

Current, valid and unrestricted licensure for practice required with proof on date of hire. Re-verification will take place no less than every 3 years.

Utilization Review clinicians are required to be educated in current principles, procedures and knowledge of behavior health.  They must be a licensed behavioral health clinician and practice within the scope of their licensure with a minimum of 2 years behavioral health experience.  Managed care experience preferred
A staff providing utilization review services will have at least one of the following:
• Master’s degree or higher in a health related field and licensure as a behavioral health professional.
• RN, licensure as a professional

Send Resumes: employment@beaconhs.com
visit us at www.beaconhealthstrategies.com