York, PA | Professional | Tracking Code: 90695

Utilization/Care Manager - Quest

James Kane
James Kane
Sr. Talent Acquisition Consultant

Job Description:

Under the general supervision of the Director-Case Management (Quest Behavioral Health), performs a variety of reviews and applies utilization and case management techniques to determine the most efficient use of resources to support the provision of appropriate, cost effective and quality treatment. Assists in the organizing of utilization reports and revision of clinical policies and procedures as required.

 

Duties and Responsibilities

 

  1. Performs initial reviews for medical necessity and appropriateness of setting for the assigned case load.
  2. Conducts concurrent reviews to ensure medical necessity for continued hospitalization and initiates problem-solving techniques as needed to prevent over and/or under utilization.
  3. Liaisons with the treatment provider regarding the identified treatment plan in accordance with concurrent review criteria.
  4. Assists the treatment provider in identifying and coordinating alternative, least restrictive settings that will provide appropriate and qualitative care while controlling cost.
  5. Identifies conditions that require case management across the member’s episode of treatment or between treatment episodes. Collaborates with the treating provider to identify the member’s needs including those beyond the immediate clinical treatment administered by the provider.
  6. Coordinates services with medical utilization/care management personnel of other health plans to ensure appropriate, cost effective treatment and identify areas where both utilization management personnel can collaborate.
  7. Assists with the collection and analysis of utilization data and tracks ongoing care management cases and their outcomes.
  8. Brings known or suspected problems of under-, over-, or inappropriate utilization of resources to the attention of the appropriate manager(s).
  9. Prepares and maintains appropriate documentation as required.

 

 

Qualifications

  • Notes:
    • Other combinations of formal education, training and experience may be considered.

 

  • Minimum Experience:
    • 5 years post graduate experience as a provider of behavioral health treatment services
    • CISM experience or training preferred. 

 

  • Minimum Education:
    • Master’s Degree in Psychology or Social Work with a current and active license from the Pennsylvania Board of Examiners or a RN with certification in Psychiatry. Will also consider a masters degree in Social Work, Psychology or Counseling

 

  • Minimum Field Of Expertise:
    • Previous quality assessment and utilization management experience

 

  • Preferred Education:
    • Doctorate Degree (Ph.D. or Psy.D.)

 

  • Skills:
    • Good communications skills; organizational skills
    • Close computer work, mostly telephonic service; Shared cubicle office area with other utilization/care managers

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