Utilization Management Specialist II

• Master’s Degree in Social Work, Psychology, Counseling, or related Human Services field is required.
• Licensed Clinical Social Worker (LCSW), Licensed Psychologist (LP), Licensed Professional Counselor (LPC), or Registered Nurse is required. Licensed Clinical Drug and Alcohol Counselor (LCADC) is preferred.
• Minimum of five years’ experience in the mental health and substance abuse field required; experience with all target populations and direct experience performing benefits and/or utilization management in a managed care setting preferred.
• Understand current DSM (Diagnostic and Statistical Manual) and ASAM (American Society of Addiction Medicine) Medical Necessity Criteria and demonstrate competence in making mental health and chemical dependency provisional diagnoses and level of care recommendations with available information.
• Understand mental health and chemical dependency inpatient, partial hospital, intensive outpatient program (IOP) and outpatient modalities based on an assessment and medical necessity criteria.
• Can relate and discuss benefits, medical necessity, and clinical information with provider network.
• Knowledge and background with managed care and insurance.
• Must possess a current valid driver’s license in good standing in state of employment and be insurable by the designated carrier. This role is required to drive for company purposes.

• Travel up to 10% may be required to conduct site visits, attend meetings and conferences.

• Maintain prominent level knowledge of behavioral health utilization management criteria and best practices including coordination of care with insurance companies, Medicaid, and other payor sources. Provides, analyzes, and documents collaboration with stakeholders to ensure the consumer receives the most appropriate level of care as designated by medical necessity criteria. Records and analyzes Utilization Management Outcomes to identify trends in stakeholder response to the consumer’s needs.
• Familiarity with current provider manuals by insurer. Provides information to the treating provider(s) regarding insurance plan specifications of the treatment of substance abuse and mental health.
• Recommend new models and innovative practices to improve UM functions and cross-collaborative service efficiencies and effectiveness.
• Model behavior and initiatives consistent with the Pinnacle Treatment Centers mission, vision and values and board focus areas.
• Identify statistical, programmatic, and clinical outliers utilizing the outlier management database and established agency protocols. Analyze the outlier data, prioritize the data for further analysis and review, and collect sufficient data to complete the consultation process with each affiliate in a manner that seeks to build collaborative relationships with each provider. Analyze the outlier data to identify opportunities for regional development and performance improvement. Fully document all data collected and all analyses conducted during the review process. Develop action plans jointly with relevant providers to address the outliers when required, based on established agency protocols. Provide or arrange onsite reviews/consultation for unresolved outlier management issues and provide final recommendations based on the site review outcome.
• Provide utilization data for performance improvement and regional development purposes.
• Identify quality concerns related to programs, specific practitioners, or consumers, and notify the provider and relevant oversight committees (if relevant) of them.
• Review behavioral health companies updated clinical information on a timely basis for the purpose of utilization management certification, continued stay, and transition of care.
• Perform daily utilization management functions at designated Recovery Works/Pinnacle location(s) and take appropriate action when necessary. Close communication with the facility treatment teams and accountability to inform leadership of any issues pertaining to complete, accurate, timely documentation.
• Process appeals with managed care companies. Ensure documentation submitted is complete, accurate, and timely.
• Participate in multidisciplinary team and Flash meetings for current clinical status and to maintain consistency in documented issues in the Electronic Medical Record.
• Assist in case management and transition of care duties as assigned.
• Maintains tracking mechanisms including database administration and file administration for recordkeeping and information retrieval as directed.
• Provides administrative and clerical support to designated Clinical, Medical, and Revenue Cycle Management departments.
• Prepares presentations, special reports, correspondence, and documentation of meetings.
• Utilizes clinical supervision and consultation appropriately to ensure work within scope of practice.
• Maintains the confidentiality of consumer and other information.
• Other duties as assigned.

• 18 days PTO (Paid Time Off)
• 401k with company match
• Company sponsored ongoing training and certification opportunities.
• Full comprehensive benefits package including medical, dental, vision, short term disability, long term disability and accident insurance.
• Substance Use Disorder Treatment and Recovery Loan Repayment Program (STAR LRP)
• Discounted tuition and scholarships through Capella University

Pinnacle Treatment Centers