Utilization Review Coordinator - Behavioral Health (Temp)

Umpqua Health is a Coordinated Care Organization (CCO) in Roseburg, Oregon that serves over 30,000 OHP members within Douglas County, offering benefits, programs and outreach for those in need. Currently we are seeking a Utilization Review Coordinator - Behavioral Health, to join our Behavioral Health team.

• Full-Time or Part-Time options for Limited Duration (TEMP) Position, in Roseburg, Oregon.
• Generous benefit package including; PTO, Health/Vision/Dental Insurance, 401k with a company match, gym membership reimbursement and more.
• Salary is dependent upon experience.

The Utilization Review Coordinator (URC) performs clinical reviews for Umpqua Health Alliance (UHA) to determine the medical necessity of requested services based on applicable Medicaid/Medicare policies and criteria. The Utilization Review Coordinator will adhere to regulatory compliance requirements, department quality metrics and provide exceptional customer service to all internal and external customers.

ESSENTIAL JOB RESPONSIBILITIES

• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and internal and external guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
• Conducts prior authorization and HRS flex reviews to determine medical necessity and appropriateness of services and financial responsibility.
• Processes requests within required timelines.
• Refers appropriate prior authorization and HRS flex requests to Medical Directors.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to work with the care coordinators to ensure member receive integrated care coordination as needed.
• Adheres to Umpqua Health policies and procedures and State, Federal and local regulations.
• Advanced knowledge of the Oregon Administrative Rules (OAR) governing the Oregon Health Plan as well as all applicable Medicare guidelines. Referring to OHP/ Medicare websites as needed. This includes the understanding of the policies and procedures that apply to the Appeal and Grievance process and the Member’s Rights and responsibilities as stated by the Division of Medical Assistance Program (DMAP) as well as CMS.
• Ability to demonstrate an ongoing understanding and current knowledge of benefits for OHP/Medicare required.
• Work together with the Third-Party Recovery (TPR) department regarding any member with the potential for additional insurance coverage as well as reporting any case that may reach stop loss.
• Work with Customer Care department regarding eligibility issues including when a member has a change in address or moved out of area.
• Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost-effective care delivery.
• Responsible to ensure that treatment delivered is appropriately utilized and meets the member's needs in the least restrictive, least intrusive manner possible.
• Conduct low level audits to identify and rectify process improvement opportunities.
• Understand and participate in the discharge planning associated with inpatient/residential prior authorization reviews to ensure treatment plans and transitions of care are successful for members transferring to higher or lower levels of care within an allotted timeframe.

QUALIFICATIONS

Minimum Qualifications:

• Current RN, LPN, RT, LCSW, LPC, LMFT, Licensed Psychologist or equivalent license with 5+ years’ experience with varied medical and/or Behavioral Health exposure and capability required. CACD I and higher for Behavioral Health position(s).
• Proficient knowledge and understanding of medical and Behavioral Health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits.
• Maintain understanding of the laws, regulations, policies, and evidence-based, clinical criteria governing Oregon Health Plan (OHP) and Coordinated Care Organizations (CCO). This includes but is not limited to: Oregon Administrative Rules (OAR), Code of Federal Regulations (CFR), Oregon State Legislature (ORS), Prioritized List of Health Services, Division of Medical Assistance Program (DMAP) and Centers for Medicare and Medicaid Services (CMS).
• Proficient PC navigational, MS Office (Word, Excel, Outlook), data entry, and internet research skills.
• Proficiency with basic office equipment skills such as computer keyboarding, web-based phone queues and systems, cloud-based document storage, etc.
• Ability to type at least 45 wpm with a high degree of accuracy.
• Knowledge of basic data analytic skills.
• Experience following established medical/clinical guidelines.
• No suspension/exclusion/debarment from participation in federal health care programs (e.g., Medicare/Medicaid)

Preferred Qualifications:

• 2+ years' experience in medical field and/or managed care/utilization related field. Experience includes acute care, case management, including cases that require rehabilitation, home health, Behavioral Health and hospice treatment.
• Basic experience in quality improvement initiatives and population health management.
• Basic understanding of appropriate case management/treatment plans.
• Basic understanding of health plan benefits and options available outside contractual benefits.
• Basic interpersonal, written, and oral communication skills.
• Ability to provide exemplary customer service to internal and external customers.
• Establishes and maintains relationships with community services and providers.
• Experience considering the impacts of the work on multiple communities, including communities of color, in technical analysis.
• Experience working on a diverse team with different communication styles.
• Ability to effectively collaborate with others and function as a part of a highly functioning team.
• Ability to work effectively with a team, other departments, and exercise sound judgment in handling assigned tasks including maintenance of strict confidentiality.
• Ability to use computerized systems for data recording and retrieval.
• Ability to work well in team setting, as well as independently, be flexible and adapt to different dynamics in a fast-paced
• work environment.
• Advanced proficiency with critical thinking and time management skills required to organize and prioritize workload according to goals and specified turnaround times.
• Demonstrated transferable knowledge, skill, and ability to complete job duties independently and proficiently.
• Willingness to learn new skills and take on new responsibilities.
• Ability to support organizational and program-specific mission and goals.
• Understanding of contractual benefits and options available outside contractual benefits.
• Assures patient confidentiality, privacy, and health records security.
• Maintains current clinical knowledge base and certification.
• Ability to work independently with minimal supervision.
• Must be able to function as part of a collaborative, cohesive community.
• Demonstrated ability to identify barriers to a successful care management path.
• Working knowledge of community services, providers, vendors, and facilities available to assist members.
• Clinical knowledge of the health or social work needs for the population served.
• Demonstrated ability to identify barriers to a successful care management path.
• Assist in transition/discharge planning for members discharging from acute care settings or those who are transitioning from long term care, the Oregon State Hospital, or other residential facilities to ensure a smooth transition back to community-based supports.
• Ensure discharge/transition plans are evaluated holistically from physical and Behavioral Health perspectives.
• Strong knowledge of available community resources.
• Demonstrated competency working with people from diverse cultures. Ability to assess and treat clients in a culturally competent manner.
• Assures patient confidentiality, privacy, and health records security.
• Develop analytical and strategic problem-solving skills.
• Ability to perform quality improvement audits and report findings.
• Advanced proficiency with self-discipline to meet deadlines and follow policies, procedures, and workflows in a remote environment.
• Ability to organize work and remain focused under stressful conditions with critical attention to detail accuracy and timeliness.
• Must be able to organize and prioritize work, be proactive, take initiative, follow through, and simultaneously manage multiple priorities to ensure goals are met in a timely manner. High attention to detail.

For more information or to apply visit our website at www.umpquahealthcareers.com