Overview

Assumes responsibility, accountability and leadership for the daily operations including coordination of work, quality, and service. First line supervisor in the Utilization Management Department. Facilitates the work of assigned team members. Provides a leadership role in ongoing utilization review competency assessment, needs identification and educational offerings. Provides educational services to the Utilization Management staff. Participates in the work activities of assigned teams. Responsible for review of clinical information received from providers ensuring clinical data is substantial enough to meet Medical Necessity Criteria to authorize services as needed. Requires knowledge of managed care contracting, Medical Necessity, CMHRS services, DMAS protocols, clinical protocols and clinical review requirements. Requires knowledge of contractual, regulatory and compliance requirements for government payers, self funded and commercial payers. Ensures appropriate and accurate information is entered into claims system for processing of payment.<br /><br />Qualifications<br /><br /><strong>Education Level</strong><br />Master's Level Degree OR<br />RN-Bachelor's Level Degree<br /><br /><strong>Experience</strong><br />Required: Clinical – 3 years, Related – 3 years<br /><br />Preferred: Supervisory – Previous experience<br /><br /><strong>License</strong><br />Required: License Clinical Social Worker, Registered Nurse<br /><br />Preferred: None, unless noted in the "Other" section below<br /><br /><strong>Skills</strong><br />Required: <br /><br />Preferred: None, unless noted in the "Other" section below<br /><br /><strong>Other</strong><br />BSN or Master's in Social Work required. 3 years experience working in either in patient or outpatient services dealing with authorizations and medical necessity criteria and 3 year experience working with vulnerable populations. Virginia RN license or LCSW required.


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