Description

UPMC Community Care Behavioral Health (CCBH) has an exciting opportunity for a full-time Precertification Care Manager to support the Department of Care Management!

The Precertification Care Manager will work Tuesday through Saturday in a remote capacity! Tuesday through Friday, the hours will be 10 a.m. to 6:30 p.m., while the hours are 7:30 a.m. to 4 p.m. on Saturday shifts. Rotating holiday, weekend, and occasional evening/night coverage availability is required, as the Precertification team is a 24-hour operation. 

The Precertification Care Manager is responsible for documenting and reviewing clinical information, and making authorization determinations for adult and child/adolescent members being referred to acute and non-ambulatory mental health and substance use disorder levels of care for all Community Care contracts. This role will also be responsible for crisis management and referring members to appropriate services based on triage assessment. The Care Manager represents the organization to providers, member groups, and families, and participates in the overall administration of clinical operations while executing their responsibilities consistent with the applicable Community Care Policies and Procedures. This individual is expected to bring a level of clinical leadership to the care management department, and may serve as the care management lead for other members of their team.

Responsibilities:

• Coordinates, reviews, and maintains daily logs for reporting purposes and for weekly preparation and analysis of trending reports to address member incidents, provider deficiencies, and quality of care concerns.
• Independently problem solves based on advanced-level knowledge of the service delivery system, clinical treatment, diversion resources, and the provider network for adult and child/adolescent members for behavioral health and SUD providers from the requested region, member services policies, members' rights and responsibilities, and the operating practices of the organization.
• Responds to deadlines and has work completed on or before deadline 95% of the time.
• Identifies need for and facilitates linkages for members and families between primary care and behavioral health providers and other social services or provider agencies to develop and coordinate service plans.
• Maintains an understanding of behavioral health benefits and remains current on covered benefits, limitations, exclusions, and policies and procedures in regard to services.
• Is able to provide members, providers, and other stakeholders with accurate information concerning benefits and coverage.
• Demonstrates excellent clinical, written, and oral communication skills.
• Utilizes supervision with team coordinator and clinical manager regularly.
• Assumes responsibility for completion of acute and non-ambulatory precerts and application of appropriate medical necessity guidelines.
  • Precerts include adult and child/adolescent members from all Community Care being admitted to mental health and substance use disorder services, as well as after-hours/weekend completion of precerts for UPMC Health Plan Commercial and SNP lines of business.
• Assists with moving members to in-network facilities or coordinating with appropriate Community Care contracts regarding approval for out-of-network service utilization.
• Consults with appropriate physician advisors, as needed, for case collaboration and care planning.
• Develops specific clinical interventions and coordinates with the assigned Community Care contract and care management team for members who do not maintain regular contact with their behavioral health provider as recommended contributing to frequent crises, recidivism, and interfering with maximum benefit from available care.
• Participates in professional development activities to further clinical skills and knowledge.
• Works as part of a team providing clinical expertise and knowledge to member services and other care management staff.
• Demonstrates advanced level of computer operation with electronic medical record systems and Microsoft Outlook, Word, and Excel Programs, as well as advanced typing proficiency.
• Receives and responds appropriately to complex calls, including after-hours/weekend Employee Assistance Program calls, triage calls, and provider or member complaints.
  • Ensures accurate, thorough, and correct documentation of these calls.

Qualifications

• Pennsylvania Licensure in health or human services field (LSW, LCSW, LPC, LMFT) and Master's Degree OR licensed RN (BSN preferred).
• Minimum of three years of relevant clinical experience.
• Experience with both adult and child/adolescent populations and mental health and substance use disorder services strongly preferred.
• Experience in managed care strongly preferred.
• General knowledge of best practices in behavioral health, emphasizing work with special needs or priority populations and in public sector systems.
• Certification in substance use disorders helpful.
• PCPC 3rd Edition, ASAM, and Confidentiality Training preferred.
• Supervisory or other leadership experience in behavioral health also preferred

Licensure, Certifications, and Clearances:
Behavior Specialist OR Clinical Social Work OR Licensed Mar & Fam Therapist OR Licensed Social Worker OR Professional Counselor OR Psychologist OR Registered Nurse Pennsylvania Licensure: RN, LSW, LCSW, LPC, licensed MFT

• Clinical Social Worker (CSW) OR Licensed Marriage & Family Therapist OR Licensed Professional Counselor (LPC) OR Licensed Social Worker (LSW) OR Psychologist OR Registered Nurse (RN)
• Act 73 FBI Clearance
• Act 34 Criminal Clearance with Renewal
• Act 33 Child Clearance with Renewal

UPMC is an Equal Opportunity Employer/Disability/Veteran

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