Behavioral Health Medical Management Specialist-Utilization Review
Position Purpose: The Medical Management Specialist is responsible for completing prior authorization and concurrent reviews for behavioral health services by utilizing pre-approved criteria and guidelines to validate medical necessity. Medical Management Specialist also reviews appropriateness of discharge planning; coordinates discharge planning with outpatient providers; issues Notices of Actions and participates in clinical rounds.
- Conducts prior authorization and concurrent reviews.
- Assessment of post discharge needs and coordinates of services.
- Refers members to care management and disease management programs.
- Completes Notices of Action or Notices of Decision and maintains accurate clinical documentation of authorizations, case management, concurrent review and discharge.
- Serves as subject matter expert for behavioral health services, and as a resource for program specialties, including cultural appropriateness.
- Provides support and technical assistance to SHCA and SHCA network of care providers based on the needs of members or of a specific provider.
- Consults with Medical Director as need to review complex cases.
- Performs other similar duties as assigned.
- Ability to work remotely.
Education / Experience / Other Requirements
- This position requires a Master’s degree in a behavioral health field, Registered Nurse or an equivalent combination of education and experience sufficient to successfully perform the essential duties of this position.
- This position also requires an independent behavioral health license for the state of Arizona.
Years of Experience:
- Minimum 2 Years of experience in behavioral health field.
- Demonstrated experience working with children and adults with BH needs.
- Preferred experience with prior authorization and concurrent review process.
- Knowledge of Arizona Medicaid system and behavioral and AHCCCS health systems; psychiatric diagnoses, psychiatric medications and standards of care
- Knowledge of medical necessity criteria; managed care principles
- Ability to prioritize and effectively handle multiple projects
- Communicate effectively both verbally and in writing
- Use of a variety of computer-based technologies including Microsoft Office applications;
- Ability to work effectively and efficiently as a team member or independently