Psychiatric Residential Treatment Facility (PRTF) Care Manager - BH

• Monitors residential level of care services related to mental health and substance abuse treatment to ensure medical necessity and effectiveness.

• Provides telephone triage, crisis intervention and emergency authorizations as assigned.

• Performs concurrent reviews for residential care and other levels of care as allowed by scope of practice and experience.

• In conjunction with providers and facilities, develops discharge plans and oversees their implementation.

• Performs quality clinical reviews while educating and making appropriate interventions to advance the care of the member in treatment.

• Provides information to members and providers regarding mental health and substance abuse benefits, community treatment resources, mental health managed care programs, and company policies and procedures, and criteria.

• Interacts with Physician Advisors to discuss clinical and authorization questions and concerns regarding specific cases.

• Participates in quality improvement activities, including data collection, tracking, and analysis.

• Works with community agencies as appropriate. Proposes alternative plans of treatment when requests for services do not meet medical necessity criteria.

• Participates in network development including identification and recruitment of quality providers as needed.

• Advocates for the patient to ensure treatment needs are met.  Interacts with providers in a professional, respectful manner that facilitates the treatment process.

• Serves as the primary point of contact throughout the treatment episode at the levels of care.

• Maintains a caseload of members enrolled in the case management program, including risk stratification of members, monitoring reassessment needs and facilitating transitions of care settings.

• Maintains timely, complete, and accurate documentation in compliance with regulatory policies and procedures.

• Coordinates with the interdisciplinary team of providers, vendors, facilities, discharge planners, nurses, social workers, care coordinators, and member/caregivers to effectively manage care plans and transitions of care settings.

• Participates in complex case rounds and/or meetings and consults with Physician Adviser/Medical Director on regular basis concerning the progress of members.

Under general supervision, and in collaboration with other members of the clinical team, authorizes and reviews utilization of mental health and substance abuse services provided in inpatient and/or outpatient care settings. Collects and analyzes utilization data. Assists with discharge planning and care coordination. Provides member assistance with mental health and substance abuse issues, and participates in special quality improvement projects.

• Monitors inpatient and/or outpatient level of care services related to mental health and substance abuse treatment to ensure medical necessity and effectiveness.
• Provides telephone triage, crisis intervention and emergency authorizations as assigned.
• Performs concurrent reviews for inpatient and/or outpatient care and other levels of care as allowed by scope of practice and experience. 
• In conjunction with providers and facilities, develops discharge plans and oversee their implementation. 
• Performs quality clinical reviews while educating and making appropriate interventions to advance the care of the member in treatment.
• Provides information to members and providers regarding mental health and substance abuse benefits, community treatment resources, mental health managed care programs, and company policies and procedures, and criteria.
• Interacts with Physician Advisors to discuss clinical and authorization questions and concerns regarding specific cases.
• Participates in quality improvement activities, including data collection, tracking, and analysis.
• Maintains an active work load in accordance with National Care Manager performance standards. 
• Works with community agencies as appropriate. Proposes alternative plans of treatment when requests for services do not meet medical necessity criteria. 
• Participates in network development including identification and recruitment of quality providers as needed. 
• Advocates for the patient to ensure treatment needs are met.  Interacts with providers in a professional, respectful manner that facilitates the treatment process.

Other Job Requirements

Responsibilities

Licensure is required for this position, specifically a current license that meets State, Commonwealth or customer-specific requirements. 
One or more of the following licensure is required for this role with necessary degrees:  CEAP, LMSW, LCSW, LSW, LPC or RN.
Minimum 2 years experience post degree i