Oct 19, 2019
Who we are: Meridian, a WellCare Company, is part of a national network of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry. We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in Michigan, Illinois, Indiana, and Ohio. As a part of the WellCare Family of companies, we deliver healthcare excellence to millions of members nationwide. Our associates work hard, play hard, and give back. Meridian associates enjoy an exceptional experience and culture including special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities. A Day in the Life of a Behavioral Health UM Care Manager (LMSW / LPC): Provides behavioral health care management services through prospective, concurrent and retrospective evaluation and review of treatment. Determines medical necessity, level of care required and quality of care provided. Coordinates and manages behavioral health services rendered by network and non-network providers to health plan members using InterQual criteria, clinical skills and expertise, persuasive communication and access to care standards to promote cost-effective quality outcomes. Oversees and coordinates all facets of care management including initial contacts, necessary triage, pre-certification, administrative and clinical concurrent review, discharge and aftercare planning/referrals and linkage of patients to appropriate mental health providers and outside agencies for follow-up care.
Performs behavioral health triage and crisis management services. Links and coordinates services with medical/surgical departments and other outside agencies, such as transportation and home health care. Coordinates psychiatric diagnoses, behavioral health treatment services, and psychotropic medications with behavioral health providers and physician advisors. Refers members to the appropriate level care and reviews and authorizes care services using InterQual criteria and medical necessity guidelines. Documents treatment authorizations and monitors, tracks and reports behavioral health care utilization. Conducts all necessary direct utilization management activities for behavioral health plan members including service coordination for members in crisis, crisis intervention, behavioral health triage, crisis assessment services, pre-certification and authorization of care for both psychiatric and chemical dependency services, all necessary concurrent review with hospitals and mental health centers, discharge and aftercare planning and referrals for continued outpatient care. Interacts on a daily basis with hospital representatives and attending psychiatrists and coordinates physician-to-physician reviews with the medical director. Reviews treatment plans and consults with medical director regarding medical necessity criteria for continued inpatient stay. Facilitates community placements, agency linkages and coordinates discharge planning, aftercare, referral and follow-up of inpatients. Documents, monitors, tracks, and reports authorizations, denials, treatment plans, clinical findings, progress notes, and case dispositions related to behavioral health services using automated and manual systems and formats. Monitors, tracks and reports cases. Monitors utilization trends by hospital and attending psychiatrist with emphasis on managing high volume providers. Identifies high risk/high volume members for more intensive follow-up care and conducts hand-off coordination between Clinical Coordinators and providers. Coordinates community resources with emphasis on the development of natural support system. Coordinates benefits, regulations, laws and public entitlement programs. Applies psychological and counseling theory and industry standard clinical guidelines with the appropriate ICD-9/DSM IV diagnosis. Maintains HIPAA standards and confidentiality of protected health information. Reports critical incidents and information regarding abuse and neglect. Ensures members have access, availability and quality care according to standards. Participates in case conferences regarding high risk/high volume regarding provider and hospital issues. Attends and participates in other HBH work groups and meetings as required. Responds to incoming telephone calls as assigned, meeting or exceeding the standards for phone access and availability in order to meet the needs of members served by the department. Performs all other clinical and administrative duties as assigned.
What you can bring to Meridian: Master’s Degree in Social Work or related mental health field is required Current licensure Licensed Register Nurse (RN) Licensed Master Social Worker (LMSW) Licensed Professional Counselor (LPC) Licensed Clinical Social Worker (LCSW) Licensed Clinical Marriage & Family Therapist (LCMFT) Licensed Clinical Mental Health Counselor (LCMHC) Licensed Psychologist Licensed Marital and Family Therapist (LMFT) Licensed Mental Health Counselor (LMHC) 2+ years of experience in using clinical criteria to determine level of treatment. 1+ year of experience in clinical behavioral health experience providing direct patient care services Experience providing care management or utilization management services in a managed behavioral health organization, community mental health center, health plan or hospital Knowledgeable of and comply with state and federal statutes, rules and policies that affect the members Must possess working knowledge of Behavioral Health utilization review, clinical levels of care, Public sector mental health, NCQA, state specific mental health codes and regulations Ability to create, review and interpret treatment plans Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions Demonstrated written communication skills Ability to effectively present information and respond to questions from families, members, and providers Other Ability to provide crisis intervention services to members under the supervision of the medical director Ability to effectively present information and respond to questions from peers and management Knowledge of healthcare delivery Intermediate expereince with Healthcare Management Systems (Generic) What Meridian can offer you: Our healthcare benefits include a variety of plans that are effective on the first day of employment for our new full-time team members. Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities. Meridian offers 401k matching that is above the national average. Full-time Meridian employees are eligible for tuition reimbursement towards Bachelor’s or Master’s degrees. Meridian was named Detroit's #1 Fastest Growing Company by Crain's Magazine, so it is a great time to get involved with Meridian. Equal Opportunity Employer #MSTR
Professional Diversity Network
Detroit, MI, USA