Behavioral Health UM Clinical Review Specialist

HealthPartners is hiring a Behavioral Health UM Clinical Review Specialist. 

POSITION PURPOSE: 

• Accurate application of HealthPartners evidence based coverage criteria in alignment with member benefit plan

• Appropriate management of HealthPartners fiduciary responsibilities in alignment with employer expectations

• Responsible for making accurate coverage determinations for the patient that are timely, reliable, accurate, and consistent.

• Serve as subject matter expert on complex utilization management issues for internal and external customers.

ACCOUNTABILITIES: 

• Maintain an understanding of state and federal regulations, accreditation standards, HealthPartners products and networks, member contracts and Health Plan policies and procedures related to Utilization Review

• Responsible for assessing, monitoring and authorizing services for coverage of inpatient and outpatient, mental health and substance use disorder utilizing thorough knowledge of multiple criteria sets and products.

• Responsible for making coverage determinations and communicating relevant information to providers and members to facilitate utilization management, coordination of care, and assist in answering questions as part of the claims adjudication process.

• Responsible for preparing documentation and consulting with the Medical Director for all potential denials that do not meet medical necessity or HealthPartners criteria. The decision for a medically necessary denial is within the Medical Director role.

• Responsible for timely and comprehensive medical review with concise documentation of pertinent facts, decisions and rationale to facilitate resolution in compliance with all regulatory requirements

• Utilize member contracts, multiple criteria sets, internal policies and procedures, Medical Directors, and other resources in the decision making process.

• Facilitate communication between physicians, providers, members and medical directors/other administrative staff to achieve consensus for coverage decisions.

Relationship & Team Building:

• Promote a positive, effective and efficient work environment and cross-functional team approach.

• Ensure all staff, processes and programs are customer-focused resulting in high levels of customer, member/patient/family, colleague, and team member satisfaction.

• Embrace change. Support an environment that encourages creativity, independence, and willingness to change.

• Develop and maintain positive, effective working relationships with colleagues, Medical Directors, providers, vendors, managed care offices and other customers.

• Function as a trainer and mentor for new staff members as requested by Leadership.

Knowledge & Education:

• Maintain knowledge of, and effectively use automated applications and systems and applicable software.

• Participate in ongoing independent study and education to develop and maintain knowledge in the areas of applicable software systems, regulatory and accreditation standards, quality improvement strategies, as well as on-boarding and training techniques.

• Maintain a thorough and comprehensive understanding of state and federal regulations, accreditation standards and member contracts in order to ensure compliance.

Customer Service:

• Consistently apply HealthPartners organizational and department values (mission/vision/values), and continuous quality improvement principles in relationships, daily work, and customer interactions.

• Responsible for accurately interpreting and correctly applying benefits, networks and product variances and clearly communicating such to members, providers and internal departments.

• Act as a liaison between internal and external customers, Marketing, Sales, Claims, Member Services, Nurse Navigators and clinics to resolve systems/process issues.

• Collaborate with physician consultants and Medical Directors to ensure consistent and comprehensive coverage decisions.

Communication:

• Efficiently and accurately communicate coverage decisions to members, providers and medical groups, following timelines established by regulations and accreditation standards.

• Identify and appropriately inform Manager/Supervisor of sensitive or complex cases.

• Able to negotiate, resolve or redirect when appropriate issues pertaining to differences in expectations of coverage, eligibility and appropriateness of