Clinical Care Manager Utilization Management
Current•Facilitating utilization by conducting reviews for Adult Acute Care, ASAM 4WM, 3.7WM, 4.0 and 3.7 LOC, ensuring members are accessing evidence-based behavioral and substance use treatments based on established medical necessity criteria.•Managing multiple providers, maintaining HIPPA compliance through encrypted emails, coordinating care level reviews, streamlining treatment histories, monitoring alerts, coordinating providers with correct departments, and completing trainings. •Collaborating with CBH Physician and Psychologist Advisors to authorize appropriate treatments, write denials, and coordinate peer-to-peer consultations, ensuring alignment with evidence-based practices and the most effective outcomes.• Consulting on complex cases at Red Flag Meetings and collaborating with multi-disciplinary teams to ensure appropriate treatment is provider and referrals for discharge planning for members.• Spearheading quality monitoring by documenting issues, coordinating quarterly meetings to address provider strengths and areas of improvement, and using data-driven strategies to improve decision-making and treatment plans. • Demonstrating leadership within the team by assisting in the training of new employees, managing coverage for absent team members, and actively participating in all assigned meetings to enhance effectiveness and care continuity.• Enhancing member treatment by providing timely responses to care coordination correspondence, ensuring immediate attention to urgent needs and fostering a supportive environment.• Following up regarding member complaints and concerns with providers and advocating on behalf of members to ensure they receive the best possible care at all times.