This position is responsible for reviewing and processing requests for authorization and notification of psychological testing and psychiatric inpatient services from health professionals, clinical facilities and ancillary providers. The incumbent will be responsible for prior authorization and referral related processes related to transitional care. Utilizes CalOptima’s medical criteria, policies, and procedures to authorize referral requests from behavioral health professionals, clinical facilities and ancillary providers. This position directly interacts with provider, facilities, and members.
POSITION RESPONSIBILITIES:
- Completes inpatient psychiatric CCR and works closely with inpatient psychiatric units to coordinate transitional care.
- Participates in weekly inpatient CCR rounds.
- Screens requests for the Behavioral Health Medical Director review, gathers pertinent medical information prior to submission to the Medical Director; follows up with requester communicates by the Medical Director’s decision; documents follow-up in the utilization management system.
- Prepares documentation for data entry into the utilization management system at the time of the telephone call of fax to include any authorization updates.
- Reviews ICD-10, CPT-4 and HCPCS codes for accuracy and existence of coverage specific to the line of business.
- Participates in ICT meetings as necessary.
- Identifies and reports any complaints to immediate supervisor utilizing the call tracking system, or through verbal communication if the issue is of urgent nature.
- Refers cases of possible over/under utilization to the Medical Director for proper reporting.
- Meets productivity and quality of work standards on an ongoing basis.
- Assists BH Manager (CM) with identifying areas of staff training needs and maintains current data resources.
- Other projects and duties as assigned.
Required Skills
- Maintain current CPT-4, ICD-10 and HCPCS codes and continual updates to knowledge base regarding the codes.
- Communicate clearly both verbally and in written formats.
- Travel to locations as necessary to meet business needs.
- Utilize and access computer and appropriate software (e.g. Microsoft Office; Word, Excel, PowerPoint) and job specific applications, e.g. CalOptima’s medical management system.
Required Experience
EXPERIENCE & EDUCATION:
- High School diploma required, Associates or Bachelor’s degree in related field preferred.
- Current LVN license to practice in the State of California required.
- 3 years of clinical experience required.
- Inpatient behavioral health experience preferred.
- Managed care experience preferred.
- Active CCM certification preferred.
KNOWLEDGE OF:
- Strong problem solving, organizational skills and time management skills with the ability to work in a fast-paced environment.
Grade: L
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