Utilization Reviewer- Care Management - Full-time or Part-time days/ eves (Ph.D. or Psy.D.)

York, PA | Professional | Tracking Code: D-UtilizationReviewCareManagement

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General Summary:


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. Organizes 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 members episode of treatment or between treatment episodes. Collaborates with the treating provider to identify the members 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 or inappropriate utilization of resources to the attention of the appropriate manager(s).
  9. Prepares and maintains appropriate documentation as required.


Department Description:


Quest Behavioral Health is a full service administrator of mental health and substance abuse benefits and Employee Assistance Programs for healthcare organizations, businesses, school districts and other employers in Pennsylvania.

 
 

 

Required Skills

Previous quality assessment and utilization management experience.

 

Required Experience

Psy.D. or Ph.D. required plus licensure; LPC, LCSW or RN license with certification in Psychiatry.


Quality of Life

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization is comprised of a multispecialty medical group of more than 1,200 physicians and advanced practice clinicians, a regional behavioral health organization, a home care organization, six respected hospitals, more than 15,000 employees, and 140 patient care locations. WellSpan is a charitable, mission-driven organization, committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Quality of Life
Quality of Life

Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation.

Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more — within an easy drive of major East Coast cities.

York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000)

Equal Opportunity Employment

WellSpan Health is an equal opportunity employer. Employment selection and related decisions are made without regard to sex, race, age, disability, religion, national origin, color or any other protected class. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

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