RN Job In Cypress, California
UM Care Manager - West RegionNext Steps... Apply Now
We are currently seeking a dynamic UM Care Manager to join our team in Cypress, CA!
About the Position:
We are currently seeking a dynamic UM Care Manager to join our team in Cypress, CA! The UM Care Manager is responsible for completing triage assessments to determine patient risk and appropriate level of care based on the medical necessity review as well as, performing ongoing utilization review, authorization for all higher levels (IP, RTC, PHP, IOP) of care (both psychiatric and substance use treatment.)
- Responds to and completes urgent/emergent assessment and triage for members in accordance to Beacon/CHIPA/Regulatory standards and guidelines.
- Logs on to phone queue and remains available to take calls from members, providers and facilities to answer any questions relating to utilization management.
- Completes pre-certification and concurrent reviews for Inpatient, Residential Treatment and Diversionary services according to clinical criteria and CHIPA/regulatory guidelines.
- Maintains a caseload of care cases for review (IP, RTC, PHP, IOP)
- Schedules and complete chart reviews with a physician advisor when indicated.
- Provides pertinent and relevant treatment and discharge plan recommendations to assist with member's care
- Requests copies of medical record when indicated
- Coordinates care for members with other treatment team members including case management team when indicated
- Schedules peer to peer review with a physician advisor according to guidelines and when indicated.
- Participate in weekly clinical rounds with interdisciplinary team, physician advisor and/or clinical supervisor/manager.
- Documents all authorizations and clinical notes in member file in the appropriate information system (IS)
- Completes retrospective reviews as assigned by UM Supervisor or Manager.
- Notifies Director of Utilization Management, Manager of Utilization Management and UM Supervisor of any quality indicators/concerns (PQI) including untoward event/incidents.
- Adheres to all Beacon/CHIPA policies and procedures and standards of operations.
- Completes all required and assigned trainings in a timely manner
- Attend and participate in all mandatory company and department meetings.
- Reports to each scheduled shift and performs essential job functions of a utilization management clinician.
- Displays a positive, constructive, and helpful demeanor that is conducive to a safe and respectful work environment.
- Acts as a mentor to new team members by leading by example and guiding with a sense of integrity and team work.
- Assist with training new hires on UM processes and workflows when assigned by UM Supervisor, Manager or Lead.
- Assist with quarterly and new hire UM clinical review file audit when assigned by UM Manager, Supervisor or Lead.
- Assists management in identifying opportunities for improvement, and training needs.
- Assist team members and offers suggestions to improve processes, culture, or work environment.
- Performs special projects and other duties as assigned and required.
- Participates in quarterly Inter Rater Reliability
- Has a good understanding to UM Guidelines, Level of Care Criteria, UM Policies and Procedures, and NCQA/ URAC standards.
- Education: Bachelor's Degree or equivalent in nursing or Master's Degree in human services, psychology or related field required
- Licensures: Current, unrestricted, valid state clinical license (LPT, LVN, RN, LCSW, MFT, PhD) required
- Relevant Work Experience: 5 years of direct patient services preferably in a behavioral health setting required
- Knowledge, Skills, & Abilities:
- Knowledge of medical necessity criteria and treatment protocols for psychiatric and chemical dependency diagnoses
- Excellent prioritization and organization skills
- Strong interpersonal skills and good written and verbal communication skills
- Advanced level of PC skills required
Click below on "Apply for this Position" to create a profile and apply for the position
Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled
AAP Reporting Location:
CA - Cypress
ID (Req #):