MHSU Utilization Management Reviewer Sun/Mon/Fri/Sat

Competitive Compensation & Benefits Package!  

Position eligible for – 

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs

See attachment for additional details. 

Office Location:  Flexible for any of our office locations

Projected Hiring Range:  Depending on Experience
 Closing Date:  Open Until Filled

Primary Purpose of Position:

This position will evaluate medical necessity, appropriateness and efficiency of the services requested for authorization against established criteria adopted by the LME/MCO.

Role and Responsibilities:  

• To respond to all requests for authorizations from the provider community with appropriate authorization decision that is guided by medical necessity and clinical guidelines
• Services are authorized based on individual need and standardized procedures
• Review and authorize initial requests, concurrent requests, urgent requests and retrospective requests
• Consulting with providers regarding authorization requests
• Consultation with Partners BHM physician regarding requests in which there is a question regarding authorization, enrollee health and safety issues, medication issues, lack of response to services and need for Peer Review when the MHSU Utilization Management Reviewer cannot approve the request for treatment
• Development of letters that communicate to enrollees and providers the reason for any adverse decision and offers information regarding the options to appeal any adverse decision
• Provide back-up coverage for afterhours triage of behavioral health crisis call line

Knowledge, Skills and Abilities:  

• Comprehensive knowledge of mental illness and appropriate treatment for major diagnostic categories; behavioral health principles, techniques, and practices, and their application to complex treatment and service provision
• Considerable knowledge of person-centered and recovery philosophies and interventions
• Considerable knowledge of assessments and interventions for mental health, developmental disability and substance use disorders;
• Knowledge of the 1915 (b) (c) waiver
• Knowledge of psychiatric medications and side effects
• Knowledge of evidence-based practices
• Awareness of cultural diversity
• Excellent computer skills including proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.)
• Ability to engage providers in collegial discussions about plans of care and best clinical practices for consumer 
• Ability to establish and maintain effective working relationships with consumers and their families as well as civic, legal, medical, social, and religious stakeholders
• Ability to express ideas clearly and concisely orally and in writing, and to plan and execute work effectively and efficiently
• Ability to utilize complex telephone and computer systems, and to read and document information electronically
• Ability to make prompt decisions based on relevant facts
• Detail oriented, able to independently organize multiple tasks and priorities, and to effectively manage an assigned caseload under pressure of deadlines

Education/Experience Required:

A Master’s Degree in a Human Services field with clinical licensure and two (2) years of post-Master’s experience in MHSU or a Registered Nurse with two (2) years of experience in MHSU, post RN degree.

Must reside in North Carolina.

Education/Experience Preferred:

Registered Nurse in North Carolina by the N.C. Board of Nursing with experience in psychiatric nursing services.

Licensure/Certification Requirements:

Current unrestricted license with the appropriate professional board of licensure in the state of North Carolina. Licensed to practice as a Registered Nurse in North Carolina by the N. C. Board of Nursing or Independent License in NC as a LCSW, LCMHC, LPA, LMFT. An Associate license does not meet the requirements.  An employee may be dual licensed with one of the specialties listed here can also be licensed as an LCAS.  NC DMA contract requirements does not allow for an LCAS to be a standalone license for working in UM. Employee is responsible for complying with respective licensure board’s continuing education/training requirements to maintain an active license.