Outpatient Case Manager

Behavioral Healthcare Providers (BHP), a division of MHealth Fairview, is hiring a Case Manager to collaborate with BHP-managed members, mental health and substance use providers, and healthplans to provide behavioral health case management and utilization management (UM) services.As a member of the BHP UM team you would work to provide effective and efficient quality of care and services to our members. BHP provides impartial access to care, and fair and consistent UM decision making that ensures the delivery of quality care while maximizing benefits and minimizing cost.

The Case Manager position engages with members to provide telephonic complex case management services, de-escalation and risk assessment, as well as access to appointments. In addition, the Case Manager works with facilities and member to provide medical necessity reviews for authorization requests.The Case Manager is knowledgeable about evaluating level of care guidelines in order to manage and service the behavioral health needs of members. In partnership with fellow medical peers, the Case Manager assesses the program needs available for each patient, develops complex care plans that meet the needs of each patient, and uses policy and regulatory guidelines to oversee processes related to plan authorization, denials, utilization, and discharge planning.

This position is scheduled 8:00am - 4:30pm and is located in Golden Valley, MN.

Utilization Review:

• Obtain the necessary knowledge of case management policies and procedures, regulatory standards and Level of Care guidelines adopted by BHP;
• Obtain the necessary knowledge concerning BHP payer products, benefit information, and system differences, as applicable;
• Obtain the necessary knowledge concering Managed Behavioral Health Organization standards outline by the National Committee of Quality Assurance (NCQA);
• Perform initial clinical review and utilization authorization recommendations with practitioners or facility utilization staff based on the Level of Care Placement Criteria and BHP standards;
• Perform concurrent reviews for continued stay and authorizations, as appropriate, or negotiate alternative treatment when clinical status lies outside criteria according to BHP criteria and standards;
• Appropriately forward all potential utilization decisions that may result in a denial onto the appropriate licensed Psychiatrist;
• Responsible for case maintenance including entering all clinical data, updates, and authorizations in the computer system, according to policy;
• Respond to provider inquiries concerning authorizations, denial and BHP policies and procedures;
• Complete all authorizations or denial telephonic and written notifications, as required;
• Upon request, provide information to members, practitioners or facilities on BHPs case management policies and guidelines;
• Provide triage and referral functions for callers indicating that their current need is a crisis situation;
• Perform anticipatory discharge planning in accordance with the patient's insurance benefits and available alternative resources;
• Collaborate with medical peers on consideration of discharge planning needs;
• Refer patients to complex case management services as needed.

Population Management:

• Educate and support the individual through telephonic assessment and expert clinical complex case management interventions;
• Evaluate delays in care, coordinate with UM functions related to discharge planning, and arrange for alternative care services to facilitate timely and appropriate discharge;
• Document all clinical information in accordance with policies and procedures in the member's electronic medical record;
• Assess and interpret beneficiary needs, gaps, and requirements related to his/her disease condition;
• Develop complex case management care plans in collaboration with beneficiary/caregiver/provider in order to promote optimal health;
• Collaborate with specialists, physicians, and medical directors to provide the necessary care and cost-efficient care for the beneficiary related to their disease condition;
• Assess the effectiveness and quality of services provided related to clinical, functional, and outcomes.

Incorporates Case Management concepts into all phases of work:

• Documents case management activities.
• Analytically apply problem-solving techniques to the case management process.
• Understand and embrace the case management philosophy and principles.
• Recognize how to evaluate the effectiveness of case management.
• Utilize strong organization skills by using planning and goal development techniques.
• Knowledgeable about potential liability issues for case management activities.
• Develop case management plans that address the individuals needs.

Required