Summary
Under the direction of the Vice President, Clinical Services, and with the guidance of the BHS Medical Director, and the EVP & Chief Clinical Officer, this position is responsible for overseeing and coordinating all patient care activities within the Clinical Services Division. Specific responsibilities include referral and case management activities across all client locations, clinical administration of client benefits and participation in utilization review and quality assurance activities.
Specific Duties:
Under the direction of the Vice President, Clinical Services:
- Perform care management coordination activities for managed care, employee assistance, and workers’ compensation beneficiaries system-wide to include: scheduling and direct case management reviews, communication with hospitals, attending physicians, outpatient providers, etc., effectiveness review and monitoring functions, quality assurance.
- Receive calls from patients, providers, and facilities; arrange for appropriate intake assessments; schedule and refer to appropriate case manager in local area. Perform appropriate monitoring activities on a regular basis. Provide coverage to the Clinical Services Division as deemed necessary.
- Explain benefits to employees, patients and treatment providers. Verify benefit eligibility and maintain appropriate communication with Client company contacts. Maintain positive interactions with patients, providers and Clients.
- Participate in utilization review and quality assurance activities, as directed. Coordinate U.R. activities with the BHS physician review panel as appropriate, to include ensuring on-going and timely peer/clinical review of active inpatient and outpatient cases.
- Adhere to established BHS clinical policies, procedures and utilization review guidelines, HIPAA standards, ERISA regulations, URAC standards.
- Review incoming claims for completeness of data and appropriate approval, in cooperation with data processing and the Accounting Division. Cooperate in data analysis process by other divisions.
- Serve as clinical liaison for EAP accounts to include communication with clients, assisting Vice President, EAP with quarterly and annual reports.
- Provide after hours coverage for emergencies on a shared basis, collecting data based on structured intake questionnaire and arranging for peer review.
- Assist in the clinical coordination of patient activities and cases as requested.
- In cooperation with the Provider Relations Division facilitate emergency case-specific facility hook-ups or transfers as deemed appropriate. Maintain contact with members as needed regarding the status of provider requests.
- Interact with the BHS physician review panel and coordinate case reviews for medical necessity purposes. Maintain strong liaison with physician reviewers and the BHS Medical Director.
- Maintain patient and departmental files, policies, procedures, budgets. Assist in achievement of annual goals, objectives and divisional action plans.
- Perform other related duties as directed or deemed appropriate. Attend meetings as directed. Maintain professional competency through continuing education, conferences, and internal training.
Qualifications:
- Masters degree in Psychology or related field required
- Active, professional licensure or certification to practice in the behavioral health field in a state or territory of the United States required
- QA/UR experience in psychiatric setting
- Minimum five years experience in mental health field
- Prefer experience in services to business and industry
- Exposure to computerized applications
- Strong organizational and communication skills