Behavioral Health Utilization Management Clinical Coordinator - Remote in Colorado preferred

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The Clinical Coordinator is responsible for processing all Behavioral Health and Substance Use Disorder authorizations within designated turnaround times for various lines of business, including RMHP DSNP, RMHP Medicare, RMHP PRIME Medicaid, RMHP RAE Medicaid, RMHP CHP+, RMHP IFP, and NHP RAE Medicaid. This role involves applying approved medical necessity criteria, escalating cases to secondary medical director review when necessary, and collaborating with leadership and medical directors on complex cases. The Clinical Coordinator proactively manages and identifies potential barriers for members, ensuring they receive necessary care and support. They refer members to the RMHP Care Coordination Department for specific needs, notify providers and requestors of authorization determinations, and offer peer-to-peer consultations when cases do not meet criteria. Additionally, the Clinical Coordinators draft denial letters, validate eligibility, input authorization requests into electronic health records, and provide assistance to callers. They complete required trainings, participate in annual Inter-Rater Reliability testing, and facilitate care coordination meetings. The role also involves engaging members in the RMHP Contingency Management Program, collaborating with facility staff, providing consultations, maintaining confidentiality, supporting evidence-based practices, establishing and maintaining professional relationships, identifying the need for higher-level reviews, formulating case overviews, administering benefits, handling escalated calls, and applying clinical knowledge to determine medical appropriateness.

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

Primary Responsibilities:

• Process all Behavioral Health and Substance Use Disorder authorizations submitted by providers within the designated turnaround times specified in the Prior Authorization List for all lines of business, including RMHP DSNP, RMHP Medicare, RMHP PRIME Medicaid, RMHP RAE Medicaid, RMHP CHP+, RMHP IFP, and NHP RAE Medicaid
• When processing authorization requests, the Clinical Coordinator applies approved medical necessity criteria and appropriately escalates cases to secondary medical director review when necessary
• Collaborates with leadership to discuss authorization requests when additional guidance is required
• Proactively manages and identifies potential barriers for members, activating appropriate entities and departments to ensure members receive the necessary care and support to stabilize
• Collaborates with the medical director on complex cases to ensure members receive appropriate treatment
• Refers members to the RMHP Care Coordination Department when specific needs are identified, ensuring they are addressed to facilitate successful aftercare planning
• Notifies providers and requestors of all authorization determinations
• When a case is determined not to meet criteria, corresponds with the requesting provider to offer a peer-to-peer consultation with the RMHP medical director, allowing the provider to present additional information before a final decision is made
• When a medical director issues a denial, the Clinical Coordinator drafts a letter informing the member and the requesting provider of the decision, the reasons for the decision, and offers alternative treatment options
• Verifies eligibility of providers and members for all authorization requests
• Inputs authorization requests into an electronic health record
• Promptly provides assistance to callers routed to the BH UM department
• Completes required trainings by the assigned due dates to comply with auditing entities such as NCQA. These trainings include, but are not limited to the following: MCG criteria, ASAM criteria, and InterQual criteria
• Participates in annual Inter-Rater Reliability testing and pass with a score of 90% or higher
• If an incomplete authorization request is submitted, the Clinical Coordinator attempts to obtain the missing information from the requestor and initiates an extension if needed
• Schedules and facilitates care coordination meetings with members who are receiving substance use disorder residential treatment. The Clinical Coordinator identifies and assists members with unmet needs, resources, and aftercare planning
• Engages members in the RMHP Contingency Management Program by submitting referrals to Care Management staff, and tracks member milestones met
• Collaborates with facility staff, attends meetings, and addresses provider concerns
• Provides consultation to providers and/or consumers on a variety of issues including benefit information, safety issues, confirmation of authorization decisions, procedures for higher levels of care evaluations, and requests for an explanation of the level of care, coverage determination, or best practice guidelines
• Respects confidentiality and maintains confidence as described in the UHG Employee Handbook. The ability to maintain confidentiality is a critical and essential component of this position
• Supports outcome-focused, evidence-based best practices and guidelines with providers
• Establishes and maintains professional working relationships with referral sources, community resources, and care providers
• Identifies and communicates network gaps in care to Leadership
• Appropriately identifies the need for secondary reviews or case consultations with the Medical Director
• Documents concise case reviews
• Manages member benefits, reviews treatment plans, and coordinates transitions between various levels of care
• Collaborates with providers and members to address gaps in care within the community, assisting members in transitioning along the continuum of care as needed
• Addresses escalated calls to resolve complex issues Ensures issues or changes are communicated and implemented as appropriate
• Applies clinical knowledge and critical thinking to evidence-based guidelines pertaining to clinical presentations. Determines medical appropriateness and appropriate levels of care
• Sends correspondence to practitioners, providers, and members regarding authorization status/updates needed
• Maintains job aids for team operations current and updated as needed

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Current, unrestricted independent licensure as a LAC, LPC, LMFT, or LSCW in Colorado
• 4+ years directly serving individuals with behavioral health conditions (mental health/substance use disorders)
• 1+ years of experience with local behavioral health providers and community support organizations addressing SDoH (e.g., food banks, non-emergent transportation, utility assistance, housing / rapid re-housing assistance, etc.
• 1+ years of experience with MS Office, including Word, Excel, and Outlook
• Substance use treatment experience and/or behavioral health treatment experience
• Ability to work Monday - Friday, 930am-6pm Mountain Standard Time

Preferred Qualification:

• Utilization Management experience

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.94 to $51.63 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.