Utilization Manager

Company Information

Our client, a nonprofit, provides a spectrum of treatments for opioids and other substance abuse disorders.

Job Duties

• The Utilization Manager is responsible for the day to day functions of collaborative communication with external case managers at referring provider facilities and/or managed care organizations (MCO) for data collection, interpretation and certification/recertification from third party payers at pre-admission through discharge, ongoing medical necessity reviews and interdisciplinary team support with respect to MCO requisites

• In addition, this position is responsible for having a thorough understanding of patient treatment plans through participative discussions with the care plan (interdisciplinary) team, identifying and referring requests for services to the Medical Director when guidelines are not met and reviewing residential services requiring MCO approval

• Obtaining the required pre-authorization/certification of specified services from the MCO and communicating end of benefit status and/or reimbursement changes to Finance and others as deemed necessary

• Conducting ongoing medical necessity reviews, which may be pre-service, concurrent and/or retrospective in nature, by evaluating clinical data and submitting appropriate documentation to update the patient/resident's status to the MCO as scheduled

• Acting as a liaison between the residential program and the MCO to better facilitate the reimbursement process

• Referring MCO denials and non-covered medical services to the directors for appeal determination and next steps

• Conducts timely and complete quality and appropriateness reviews on a representative sample of treatment records for residential service sites

• Provides Supervisory support to CASAC Counselors and Peer Workers as needed with supervisory guidance from Management/Leadership Team

• Monitors and evaluates ongoing audit for chart

• Provides direct care services to clients as needed

• Assists with the maintenance of the agency's OASAS reviews and CARF accreditation for the program, i.e., standards review and conformance auditing

• Performs other duties as assigned

Education

• OASAS CASAC Certification (with Bachelor's Degree)
• Other QHP credential such as LMSW, LMHC, LMSW-LP, or MHC-LP (with Master's Degree)
• Master's Degree in Social Work or related field

Experience & Skills Required

• Minimum of 2 years of case management and/or utilization review experience

• Strong problem-solving and advanced analytical skills necessary to read, understand, interpret and analyze statistical data

• Excellent oral, written, organizational and interpersonal communication skills

• Ability to communicate effectively with senior leadership as well as other clinical/non clinical directors, managers, staff, consultants and MCOs

• Demonstrated ability to effectively collaborate with peers and senior leadership on project assignments and group presentations

• In depth knowledge on HIPAA, OASAS, and 42 CFR regulations

• Working knowledge of quality assurance and utilization review systems

• Computer literacy including proficiency in Microsoft Office Suite and HER

• Experience working directly with people from diverse racial, ethnic, and socioeconomic backgrounds

• Competency in written, interpersonal, verbal, and computational skills to present and document records in accordance with program standards

• Ability to work independently

Reasoning Ability:

• Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Mathematic Skills:

• Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages.

Language Skills:

• Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of employees of the organization. Possess the ability to deal tactfully with personnel, clients, family members, government agencies/personnel and the general public, under all conditions/circumstances.

Certifications

• OASAS CASAC Certification (with Bachelor's Degree)
• Other QHP credential such as LMSW, LMHC, LMSW-LP, or MHC-LP (with Master's Degree
• Master's Degree in Social Work or related field

Benefits

Our client offers excellent benefits including:

Generous time off that includes 4 weeks of vacation

Medical, Dental, and Vision Insurance

Discounted Commuter benefits

Life insurance & Long term disability

Eligible for Federal Student Loan Repayment Program

Training and other additional voluntary benefits