Angela Bright Email and Phone Number

Research, interpret, and apply state and federal regulations and Virginia Department of Medical Assistance Services policy. Utilize current criteria specified in Virginia Department of Medical Assistance Services program manuals and professional clinical judgment in making decisions. Assure the provision of home and community-based services to individuals with intellectual disabilities through the most effective and efficient use of Medicaid funding through Virginia's Community-Based Care Waiver by establishing that all service/care plans funded and implemented are in compliance with regulations and policy of the DBHDS, established to comply with Medicaid regulations, and ID Waiver objectives. Research and analyze data, and identify program changes. Independently manage a caseload within established time limits. Participate in Formal/Informal Appeal hearings. Provide technical support to support coordinators and providers regarding review process and application of criteria. Complete weekly reports. Utilize education, knowledge, and skills in human services program administration/development. Utilize strong written and verbal communication skills, and word processing.

Facilitate all clinical appeals activities. Prepare synopses for clinical appeals packets. Research, interpret, and apply state and federal regulations, and Virginia Department of Medical Assistance Services policy. Review and analyze denial determinations of behavioral health services. Apply administrative approvals and fair hearing decisions to applicable cases. Research and analyze data. Identify program changes. Perform medical reviews. Utilize current criteria specified in Virginia Department of Medical Assistance Services program manuals, McKesson InterQual® Criteria, and professional clinical judgment in making decisions. Provide utilization review. Utilize knowledge of theory, principles, and practices in behavioral health sciences. Prepare cases for physician review. Independently manage a caseload within established time limits. Participate in Formal/Informal Appeal hearings. Comply with URAC standards. Provide technical support to providers regarding review process and application of criteria. Perform utilization management and authorize behavioral health services for Residential Treatment, Level A&B Group Home, Treatment Foster Care-Case Management, Intensive In-home Services, and ID Waiver services by performing professional medical review through the application of information received from health care providers to the standards of medical necessity set forth by Virginia Department of Medical Assistance Services. Utilize current criteria specified in the Virginia Department of Medical Assistance Services program manuals. Apply McKesson InterQual® Criteria. Serve as Clinical Appeals Specialist for behavioral health services. Facilitate clinical appeals activities by preparing synopses for clinical appeal packets, and applying administrative approvals and fair hearing decisions. Provide technical support to providers regarding review process and application of criteria. Prepare cases for physician review, and analyze, record, and review outcomes.

Perform utilization management of behavioral health services; determine Medicaid eligibility and authorize services for treatment foster care and residential treatment center services by performing medical review; utilize current criteria specified in DMAS program manuals; utilize professional judgement in rendering independent decisions regarding behavioral health assessments; complete requests for reconsideration of denied requests; provide technical support to providers; utilize knowledge of theory, principles, and practices in behavioral health sciences including DSM IV diagnostic groups, community & other resources available to patients, of program objectives, and federal/state regulations; utilize/update VAMMIS/First Health.