Clinical Utilization Reviewer / Community Hospital Liaison Mental Health Professional
As a Clinical Utilization Reviewer / Community Hospital Liaison Mental Health Professional, you will provide initial and ongoing utilization review services for adults and children enrolled in Adult Outpatient and Child and Family programs. Participate in all aspects of the ongoing treatment process with the primary purpose being coordination with managed care organizations, private insurance companies, tribal payers, and any other insurance source the client may have. In addition, you will provide clinical and administrative coordination and oversight between community hospitals, Western State Hospital, and KMHS Access staff, outpatient teams, and KMHS Crisis Response Team for all clients either initiating or returning to KMHS outpatient services following psychiatric hospitalization. For clients discharged on Least Restrictive Alternative who do not engage with KMHS services, provide monitoring to evaluate and document whether the client is participating in LRA required services.
Go home every day knowing your efforts helped directly serve your community and neighbors!
WHAT YOU’LL DO
CLINICAL REVIEWER ROLE
- Ensure that all clients enrolled in AOP and Child and Family Services have initial authorization set with their assigned payer.
- Track authorization dates for all clients in AOP and Child and Family Services and ensure that authorization does not lapse while clients are in care.
- Complete concurrent review process at timelines indicated by the insurance plans of clients. Assemble and release relevant information from the client’s chart in formats specified by MCO’s and AS-BHO and provide additional verbal consultation and advocacy for authorization to occur as needed.
- Support in the coordination of doctor to doctor reviews of cases when applicable.
- Participate in a collaborative leadership role with the multi-disciplinary Treatment Team. Act as an advocate for the psychiatric and social needs of the client. Provide consultation to the physician/ARNP in the development of treatment plans. Provide updates to the treatment team in regard to the authorization status of current clients.
- Maintain and submit records and documentation to meet the regulatory, agency, and funding source requirements. Follow all Records procedures related to releasing clinical information from client charts and logging all information released into Records databases. Coordinate with AOP support staff to assure that logging is completed within 14 days of authorization.
- Regularly observe the effect of current policies and inform supervisors of deficiencies in the programs, suggest special projects that may benefit programs and agency.
- Participate in QI activities, committees, and special task forces as requested.
- In addition to the above, any other responsibilities appropriate to the position and not specifically listed in the job description.
HOSPITAL LIAISON ROLE:
- Receive and process discharge summaries from external hospitals immediately upon receipt according to agency guidelines, and provide a copy to the assigned clinician.
- Provide community hospital discharge coordinators with client appointments for Access or for KMHS clinicians and prescribers (coordinated through medical assistants’ team) immediately upon the request of discharge coordinators, observing appointment timeframes consistent with agency guidelines. Assure continuity of care. Provide risk and needs assessment to clinical teams when indicated.
- Document all activities related to the above according to agency guidelines.
- Maintain contact with “LRA-monitoring-only clients” (due to not enrolling in KMHS services/having private insurance) providing referrals, counseling, psychoeducation, motivational interventions, and ongoing risk assessment to support clients fulfilling LRA requirements. Collaborate with family and collateral to motivate participation in treatment.
- Collaborate with the supervisor and Crisis Response Team to evaluate risks for clients not engaged in LRA required treatment. Evaluate the need to extend LRA’s for “LRA monitoring only” clients.
Certification as a Mental Health Professional required. Experience in a therapeutic outpatient treatment setting highly preferred. Experience in providing utilization review highly preferred.