New Directions Behavioral Health Manager Case Mgmt Utilization Mgmt in Topeka, Kansas

The Manager, Utilization Management and Case Management provides functional and administrative oversight of the Utilization Management and Case Management program and related Quality Improvement activities. The Manager provides oversight for day to day operation of the case management and the initial, concurrent and retrospective review activities. The Manager is responsible for achieving outcome measures associated with the case management and utilization management program and maintaining compliance with New Directions policies and procedures, regulatory and accreditation standards and contractual performance guarantees. The Manager is also responsible for reporting team performance and metrics in the applicable committees. The Manager assists with development and implementation of programs, policies and procedures and software systems relevant to the Case Management and Utilization Management team. The Manager regularly interfaces with multiple internal departments and external entities to facilitate the provision of contracted services and plan for future programs and activities. Work is closely coordinated with Customer Service, After Hours Service, Network Operations, Physician Reviewers, management and other staff within New Directions; client company representatives as well as all stakeholders within the behavioral health system to ensure efficient and effective management of all members and their needs. The Manager of Utilization Management and Case Management also provides direct supervision of clinical and non-clinical staff. The Manager will also provide on-call evening, weekend, and holiday supervision for after-hours staff as needed and assigned.

PERFORMANCE MEASUREMENTS

Performance is measured against both individualized and job specific annual performance evaluation goals, which may include the following: proficiency of assigned UM team’s ability to assist members with attaining 7 and 30-day discharge appointments, and coordinating to increase community tenure. These measures will be assessed and reevaluated continuously throughout the year.

ESSENTIAL FUNCTIONS

• Provides leadership for the Case Management and Utilization Management team, effectively and positively communicating corporate initiatives and motivating team members to adopt changes to enhance clinical outcomes and improve value for the customers

• Promotes quality service delivery and effective care transitions and discharge planning for optimal member health outcomes

• Provides clinical supervision and administrative oversight to UM and CM staff working with members and providers to coordinate, collaborate, and connect services in support of utilization review and post-discharge stabilization activities and movement toward self-management

• Provides timely feedback, performance reviews and performance management for CM and UM team staff on a regular basis to improve clinical outcomes for members, reduce readmissions and contribute to the value proposition for customers

• Provides caseload management and ensures that the team is working efficiently and effectively

• Provides case consultation for complex cases and situations

• Demonstrates clinical expertise in response to a variety of circumstances ranging from crisis intervention to routine business matters

• Monitor staff for appropriateness and congruence of application of medical necessity criteria during utilization review process. Provides additional training to staff as needed

• Provides education to facilities, providers and members about the case management and utilization process, including denial and appeals processes and as needed, case management processes

• Provides clinical and administrative oversight for UM and CM programs and related Quality Improvement activities. Provides reporting for programs and activities in the appropriate committee

• Facilitates daily stand up meetings, team meetings, and clinical rounds, which will include clinical case chart reviews of high risk, high cost cases and other cases upon request of supervisor, medical director or as required by policies and procedures.

• Conducts chart and phone audits and monitors individual and team scorecards. Audits will also include monitoring for compliance with ND policies and procedures as well as regulatory and accreditation standards. Provides feedback and follow-up to staff as needed to improve compliance, standardization or productivity

• Monitors daily, weekly and monthly case management and utilization reports to ensure that targets are met

• In response to escalated complaints, concerns or issues, provides information to members, providers, client company representatives and customers within applicable regulatory guidelines

• Provides and/or coordinates education and training for employees and orientation for new staff

• Collaborates with members, providers and client companies to facilitate member access to appropriate levels of care to meet their behavioral and/or physical health needs and community supports to assist them with self-management of their health

• Collaborates with providers, facilities, consultants and clients as necessary to facilitate the provision of high-quality, effective treatment services for members

• Facilitates positive interaction and collaboration with client entities to maintain client satisfaction and contract compliance

• Assists with implementation of new business/accounts as needed

• Stays current with New Directions’ technology, member Behavioral Health benefits, and non-health community resources and ensures that staff is as well

• Utilizes appropriate and standardized tools including but not limited to NDBH approved precertification, concurrent and discharge review forms, physician review tools, authorization screen, case management models, assessment instruments, practice guidelines, and other applications and tools. Ensures staff compliance with utilization of appropriate and standardized tools

• Participates in committees and projects as assigned

• Assists with the development and implementation of new programs, policies and procedures, and software as assigned by Director

• Makes recommendations of programs and/or systems that create improved outcomes and timeliness of the care management department

• Contributes to site specific audits/surveys/research projects that are relevant to care management process, policies, and procedures

• Participates in on-going continuing education as required by professional licensure, certification, or as requested by New Directions and maintains clinical licensure and certifications

• Maintains UM and CM team compliance with NDBH policies and procedures, regulatory and accreditation standards and contractual performance measures

• Promotes coordination with Health Plan medical management and medical services providers, including primary care physicians and patient centered medical homes, to promote integrated member health care.

• Accepts responsibility for follow-up and support services provided to NDBH members.

• Adheres to the policies and procedures for utilization management activities as well as screening, triage and referral activities. Monitors staff to ensure adherence to accreditation and regularly standards, including timeliness of activities/services and accuracy of documentation

• Adheres to New Directions Behavioral Health Mission Statement, Core Values, Code of Business Conduct, and Compliance Program

• Complies with all Federal and applicable State laws and New Directions Behavioral Health Policies regarding, privacy, confidentiality, and security of health information, and other designated information

EDUCATION & EXPERIENCE REQUIRED/PREFERRED

• Has a current, unrestricted license issued by a state or territory of the United States to practice independently as a Clinical Social Worker, Marriage and Family Therapist, Professional Counselor, Clinical Psychologist or Registered Nurse in the state in which the business operation is located and/or other states as required by law, regulation or contract. For Registered Nurses, a Bachelor’s Degree in Nursing is required.

• Minimum of five (5) years post-licensure experience in direct clinical care with patients in facility-based and/or outpatient psychiatric or chemical dependence treatment

• Previous experience in Utilization Management or Case Management/Disease Management

• Extensive clinical knowledge base

• Knowledge & ability to apply case management principles and concepts to their case management practice

• Excellent verbal and written communication skills and interpersonal skills are essential

• Ability to comprehend medical policy and criteria and clearly articulate health information

• Strong computer and keyboarding skills (Microsoft Outlook and Word), including the ability to document while simultaneously while taking information over the phone

• Ability to travel 5-10%

• Experience and training in Motivational Interviewing Or Health Coaching

• Ability to obtain certification in Case Management (CCM) within 3 years of hire

• A minimum of one (1) year of supervisory experience preferred

• Previous experience in managed care

• Current certification in Case Management (CCM)

• Strong computer skills including MS Office suite

• Experience and training in Motivational Interviewing

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information.

Qualifications