Responsible for carrying out discharge planning activities and medical necessity reviews on all behavioral health, alcohol & drug, and dual diagnosis members admitted for inpatient treatment, partial hospital programs and external outpatient services utilizing established criteria and guidelines. The activities will include onsite and some telephonic review of all services, referrals and coordination of transfers.  In addition they will perform eligibility and benefit reviews as necessary, discharge planning, identification of patients for case management, quality improvement reviews, education of the member/family, provider and hospital staff, and communication with inpatient care coordinators, case managers, home care reviewers, members, providers, Member Services, Claims, Contracts and Benefits - Appeals, Risk Management.

• Responsible for the day-to-day Behavioral Health case management and review activities as outlined above.  Performs an assessment of the member through the use of provider and hospital records.  Identifies members who are at high risk for: re-hospitalization and/or noncompliance with post hospital treatment recommendations.  Identification based on pre-determined criteria: new behavioral health member, history of psychiatric hospitalizations, history of noncompliance with outpatient care, severe psychosocial circumstance, and noncompliance with hospital follow up visit.  Performs admission and concurrent review on all Behavioral Health inpatient admissions as well as review of all admissions to the Partial Hospital Program utilizing established guidelines and criteria.
  • Performs precertification and ongoing review of all external outpatient Behavioral Health services.  Refers all cases that do not meet established criteria to the appropriate review physician.  Performs questionable benefit and eligibility reviews.  Develop discharge care plan with inpatient and outpatient staff.  Arranges, coordinates, and facilitates follow up appointment for the member.
  • Understands the Complex Case Management Program and admission criteria and refers patients to the Complex Case Managers as appropriate.  Provide correspondence, written and verbal, in accordance to policy and procedure for members with respect to referrals.
  • Interacts with physicians to ensure that resources are being utilized appropriately while  maintaining quality outcomes.  Responds to requests from patients and their families as appropriate, including the provision of education when needed.  Refers the patient to the home care review team and/or social workers as appropriate.  Ensures that the appropriate level of care is being delivered in the most appropriate setting based on established criteria and guidelines.  Performs quality of care and service reviews using identified quality indicators.  Coordinates and assists the Supervisor with ongoing physician education.  Reviews the monthly analysis of statistics (cost/benefit) with the Supervisor and makes adjustments based on findings.
  • Remains knowledgeable of contract benefits and current, relevant state and Federal regulations, criteria, documentation requirements and laws that affect managed care and case/utilization management.  Maintains effective interaction/communication with members of the medical staff, nursing staff, complex case managers, the SNF rounder, home care review team, social workers, inpatient care coordinators, referral coordinators, Member Services, Claims, Contracts and Benefits-Appeals, Risk Management and Kaiser Permanente medical offices to facilitate the precertification and referral process.  Builds effective working relationships with physicians and other departments within the health plan.  Assists in the development and revision of guidelines, pathways and protocols.  Attends QRM Hospital UM meetings as requested.  Investigates, identifies and reports problems and inefficiencies in existing systems, and recommends changes when appropriate to the Supervisor.  Under the guidance of the Supervisor, Telephonic Inpatient Care Coordination and in consultation with other QRM staff, participates in the coordination, planning, development, implementation, and maintenance of all QRM policies and procedures.  Monitors utilization trends in the market area, keeping appropriate management informed.  Initiates recommendations to facilitate reductions in utilization where appropriate.  Refers cases identified as risk management, peer review or quality issues to QAIR and Risk Management.
  • Document Review Activities to include: Medical necessity for admission/procedure
  • Diagnoses, Procedures performed, Demographic Data, Physicians involved in care, Other
  • Issue letters of non - coverage to members not meeting established medical necessity criteria.  Works cross-functionally with other departments in striving to meet organizational goals and objectives.  Achieves and maintains an understanding of relevant state and federal regulations, criteria, and documentation requirements and laws that affect managed care, home health and case/utilization management.  Knowledgeable and compliant with regional personnel policies and procedures.  Knowledgeable and compliant with QRM departmental and unit specific policies and procedures.
  • Participates in annual regional and departmental compliance training.  Knowledgeable and compliant with Principles of Responsibility.  Responsible for assisting the Medical Office Administration, Customer Services and Provider Relations in investigating concerns and issues.  Access to protected health information (PHI) will be limited to the minimum necessary required to effectively perform the job.  Demonstrates understanding of HIPAA privacy regulations by maintaining confidentiality of Protected Health Information (PHI).
  • Demonstrates doing the right thing and doing things the right way is an underlying premise in all work related activities and is able to identify location of copy of Principles of Responsibility.  Develops and maintains an awareness of how to report compliance issues and concerns. Identifies issues of wrong doing and promptly investigates and reports to immediate supervisor or Director of Regional Compliance. Assures an atmosphere and culture for staff to report issues of wrong doing.  Other duties as assigned.