Job Category: Utilization ManagementJob Description: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 planAppropriate management of HealthPartners fiduciary responsibilities in alignment with employer expectationsResponsible 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 ReviewResponsible 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 requirementsUtilize 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 treatment recommendation.Maintain confidentiality of member and case information by following Corporate Privacy policies pertaining to protection of member PHI.Demonstrate responsiveness to, and appreciation of constructive feedback and recommendations for personal growth and development.Respond to Member Appeals and MDH (Minnesota Department of Health) inquiries as requested by the Appeals area.Perform other duties as assigned.REQUIRED QUALIFICATIONS:Currently licensed in Minnesota as a Mental Health Professional.Minimum of 3 years clinical practice experience; minimum of 3 years relevant utilization review, discharge planning, or case management experience; and current clinical knowledgeEffective clinical judgement and skills.Excellent verbal and written communication and interpersonal skills.Excellent problem identification and solving skills.Ability to organize and prioritize multiple assignments within workloadAbility to function independently and take independent action, within the scope of job responsibilities.Competency in personal computer skills including Microsoft word, Outlook and Internet.Ability to deal with change and ambiguity.PREFERRED QUALIFICATIONS:Minimum of one year experience in utilization review, utilization management, quality review or discharge planning.Experience in managed care environment.Experience in working with established criteria to determine medical necessity and appropriateness of care.Computer experience with word processing, excel spreadsheet management, and other utilization management applications.DECISION-MAKING: (What rules or precedents limit the activities and authority of this position? What types of problems or decisions are referred to the supervisor?)Functions independently with minimal supervision.Ability to use critical thinking skills for problem solving.Utilizes clinical judgementMakes approval and technical denial determinations within scope of practiceSummarizes and sends all potential medical necessity denial determinations to the appropriate Medical DirectorDetermines when additional resources (Medical Director, Supervisor, etc) need to be consultedAppropriately informs/refers sensitive or complex cases to Supervisor/Manager.About Us:At HealthPartners we believe in the power of good - good deeds and good people working together. As part of our team, you'll find an inclusive environment that encourages new ways of thinking, celebrates differences, and recognizes hard work.We're a nonprofit, integrated health care organization, providing health insurance in six states and high-quality care at more than 90 locations, including hospitals and clinics in Minnesota and Wisconsin. We bring together research and education through HealthPartners Institute, training medical professionals across the region and conducting innovative research that improve lives around the world.At HealthPartners, everyone is welcome, included and valued. We're working together to increase diversity and inclusion in our workplace, advance health equity in care and coverage, and partner with the community as advocates for change.Benefits Designed to Support Your Total Health As a HealthPartners colleague, we're committed to nurturing your diverse talents, valuing your dedication, and supporting your work-life balance. We offer a comprehensive range of benefits to support every aspect of your life, including health, time off, retirement planning, and continuous learning opportunities. Our goal is to help you thrive physically, mentally, emotionally, and financially, so you can continue delivering exceptional care.Join us in our mission to improve the health and well-being of our patients, members, and communities.We are an Equal Opportunity Employer and do not discriminate against any employee or applicant because of race, color, sex, age, national origin, religion, sexual orientation, gender identify, status as a veteran and basis of disability or any other federal, state or local protected class.
