Virginia Premier Health Plan Behavioral Health Utilization Reviewer in Glen Allen, Virginia
Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.
By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.
At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.
If this sounds like you, read on!
A Behavioral health Utilization Management Reviewer is responsible for the timely coordination of quality behavioral health and substance use disorder treatment services for plan membership in a cost-effective manner to promote positive outcomes. Performs utilization and care coordination for members with behavioral health needs and substance abuse disorders by assessing levels of care, and by developing, implementing, coordinating, monitoring, and evaluating plan of care designed to optimize member’s treatment across the continuum. Evaluates requests for services for clinical appropriateness and medical necessity. Responsible for authorizing cases according to approved criteria across the continuum of care to ensure a positive member outcome while controlling costs by performing inpatient and outpatient reviews, and identification and referral of members appropriate for case management.
Medical Management educates members and empowers them to become active participants in their coordinated health care plans. This team of knowledgeable professionals in their field provide services to include Utilization Review, Medical Outreach, Case Management, Disease Management, Credentialing, Social Work as well as Grievance and Appeals
Obtains, reviews and enters clinical information from callers and submitted authorization requests according to Virginia Premier’s policy and procedure manual for medical/behavioral health services requiring certification such as: pre-admission, admission, concurrent and retrospective review in Virginia Premier’s computer systems.
Reviews pre-certification requests within 1 business day of receipt to determine medical necessity for appropriateness of behavioral health care using established medical necessity criteria. Refers cases deemed questionable to the Behavioral Health Medical Director
Prepares and sends the appropriate certification or non-certification letter to the member, provider and hospital according to Virginia Premier Health Plan, Inc. (VPHP) policies and procedures
Refers potential high-risk cases which will benefit from other specialized case management services to the respective case management team
Identifies and obtains needed community resources and provides feedback to external agencies on specified cases, as necessary
Participates in continuing educational activities as appropriate
Assesses members primarily through received phone calls and develops person-centered care plans to meet service planning and service delivery needs.
Utilizes screening instruments in their assessments such as theSBIRT (Screening, Brief Screening, and Referral to Treatment), on referred members to the ARTS program to identify members who may have alcohol and/or other substance use problems.
Provides referrals for brief and immediate crisis intervention (i.e. Adult Protective Services)
Participates in Interdisciplinary Care Treatment (ICT) meetings and may offer contributions to assigned members’ overall Plan of Care (POC).
When indicated, provides a brief intervention to the member to educate them about their use, alert them to possible consequences and, if needed, begin to motivate them to take steps to change their behavior.
Coordinates and staffs complex cases with Manager of Behavioral Health, Director of Complex Care Management, and Behavioral Health Medical Director when indicated and when required by VPHP policy, NCQA standards, DMAS requirements, and/or federal requirements as applicable.
Participates in Behavioral Health or ARTS UM rounds or any combined rounds
Ensures that care coordination focuses on each individual member’s unique needs in order to provide targeted, high quality care that will improve patient engagement, regain optimal health, improve functional capability, and support long term recover in the right setting and in a cost-effective manner.
Facilitates successful care transitions between ARTS levels of care and linkage to primary care providers upon discharge from higher levels of care.
Utilizes data from multiple sources to identify members with complex health needs and substance use disorders who need help navigating the system to facility appropriate delivery of care and services.
Coordinates community resources for provision of basic services, including:
supporting proactive, collaborative multi-agency case conferences
receiving, collating and evaluating Individualized Service Plans (ISP) from facilities and providers, reviewing for appropriateness, and monitoring for care duplication and service delivery inefficiencies.
Works with members and providers to ensure smooth transitions between providers in the community to avoid any disruptions in care
Provides appropriate service referrals for members and support for their families and caregivers.
Collaborates with internal and external multidisciplinary teams to facilitate efficient and effective service planning and care coordination.
Participates in VPHP’s ongoing quality improvement projects and processes.
Practices in accordance with applicable local, state and federal laws which govern confidentiality and medical information privacy regulations (HIPAA) and 42 CFR Part 2.
Maintains accurate records and files related to work performed in accordance with VPHP policy, NCQA standards, DMAS requirements and/or federal requirements as applicable.
Other duties as assigned.
MINIMUM EDUCATION REQUIREMENTS
Licensed Clinical Social Worker with two or more years of clinical experience in the treatment of substance use disorders OR
Licensed Marriage and Family Therapist with two or more years of clinical experience in the treatment of substance use disorders OR
Nurse practitioner with two or more years of clinical experience in the treatment of substance use disorders OR
Current Virginia Registered Nurse with two or more years of Utilization Review experience preferably in the treatment of substance use disorders; BSN preferred
SPECIAL KNOWLEDGE AND/OR SKILLS
Ability to work and communicate with diverse cultural groups
Experience working within the Substance Use Disorder treatment service delivery system in Virginia
Demonstrated ability to work effectively in multi-disciplinary teams and with all levels of management and medical staff
Possess a working knowledge of ICD10 and CPT-4 coding
PC literate with working knowledge of Microsoft Word, Excel spreadsheet programs, and various computer software programs
Working knowledge of resource options, and experience in making appropriate referrals
Demonstrates ability to negotiate with providers, vendors and other deliverers of services
Minimum of 3 years relevant behavioral health/substance abuse clinical experience post-licensure
Experience with Managed Care and Medicaid Requirements
Familiar with Community Mental Health and Rehabilitation Services
Familiar with Addiction Recovery Treatment Services
- Physicalhealth sufficient to meet the ergonomic standards and demands of the position
All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE
Our mission is to inspire healthy living within the communities we serve!
Job ID 2019-5463
As an equal opportunity employer, Virginia Premier is committed to a diverse workforce. To ensure non-discrimination and affirmative action for individuals protected by Executive Order 11246, as amended, Section 503 of the Rehabilitation Act of 1973, as amended, the Vietnam Veterans’ Readjustment Act of 1974, as amended, and Title I of the Americans with Disabilities Act of 1990, as amended, Virginia Premier will consider applicants for employment without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. Applicants who require accommodation in the job application process may contact Recruitment at 804-819-5151 for assistance. It is the policy of Virginia Premier Health Plan, Inc., to comply with the requirements of the Drug-Free Workplace Act of 1988. It is a violation of our drug-free workplace policy to use, possess, sell, trade, and/or offer for sale alcohol, illegal drugs or intoxicants in our workplace. Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. Virginia Premier participates in E-verify.