Primary City/State:

Arizona, Arizona

Department Name:

Work Shift:

Day

Job Category:

Clinical Care

The future is full of possibilities. At Banner Plans & Networks, we’re changing the industry to reduce healthcare costs while keeping members in optimal health. If you’re ready to change lives, we want to hear from you.

Recognized nationally as an innovative leader in health care, Banner Plans & Networks (BPN) integrates Medicare and private health plans to reduce healthcare costs while keeping our members in optimal health. Known for our innovative, collaborative, and team-oriented approach, BPN offers a variety of career opportunities and innovative employment options by offering remote and hybrid work settings.

In the role of a Behavioral Health Utilization Care Manager, you will be tasked with assignments at various hospitals to authorize initial admissions and conduct concurrent reviews to assess medical necessity. Your work will involve collaboration with both hospitals and outpatient providers. Leveraging your clinical expertise, exceptional teamwork abilities, and strong communication skills, you will ensure adherence to compliance standards and the provision of quality care for members.

The work schedule is Monday to Friday, primarily from 8:00 a.m. to 5:00 p.m. Arizona Time Zone. The position is fully remote; however, Arizona residency is required for compliance purposes. If this role appeals to you, we encourage you to apply today!

POSITION SUMMARY

This position is the point person for all utilization activities for assigned members. As part of an interdisciplinary team, this position reviews and authorizes behavioral health and substance abuse services in inpatient, residential and outpatient settings using approved medical necessity criteria. Monitors care to ensure treatment is appropriate and effective. This position assesses the member’s plan of care and develops, implements, monitors and documents the utilization of resources and progress of the member through their care, facilitating options and services to meet the member’s health care needs. This position provides telephonic or electronic document review. This position engages internal and external resources to ensure members receive appropriate care plan and discharge planning services. This position monitors for quality of care concerns. Will staff regularly with medical directors. Within the scope of their position and licensure, this position will provide education and recommend alternative care plans for treatment not meeting medical necessity criteria. This position is accountable for the quality of clinical services delivered by both them and others and identifies/resolves barriers which may hinder effective care delivery to members. May conduct prior authorization, concurrent, retrospective, and appeal reviews.

CORE FUNCTIONS

1. Manages individual members across the health care continuum to achieve the optimal clinical, financial, operational, and satisfaction outcomes.

2. Acts in a leadership function with process improvement activities for populations of patients to achieve the optimal clinical, financial, operational, and satisfaction outcomes.

3. Evaluates the medical necessity and appropriateness of care, optimizing patient outcomes.

4. Establishes and promotes a collaborative relationship with physicians, other payers, and other members of the health care team. Collects and communicates pertinent, timely information to fulfill utilization and regulatory requirements.

5. Acts in a leadership function to collaboratively develop and manage the interdisciplinary patient discharge plan. Effectively communicates the plan across the continuum of care.

6. Educates internal members of the health care team on case management and managed care concepts. Facilitates integration of concepts into daily practice.

7. Has the freedom to determine how to best accomplish functions within established procedures. Confers with supervisor on any unusual situations. Positions are facility based with potential for remote work, with no budgetary responsibility. Internal customers: All levels of health plan staff, medical staff, and all other members of the interdisciplinary health care team. External Customers: Hospitals, physicians and their office staff, payers, community agencies, provider networks, and regulatory agencies.

MINIMUM QUALIFICATIONS

Requires master’s degree in social work, counseling or related field or with independent or associate licensure. Licensure in at least one of the following categories as required by state law: Social work, professional counseling or marriage and family. Appropriate licenses include: LCSW, LMSW, LPC, LAC, or Licensed Psychologist. Requires a proficiency level typically achieved with three years clinical experience (i.e. counseling, care management, case management, care coordination in inpatient or outpatient levels of care).

Must have a working knowledge of care management, case management, hospital and community resources. Must demonstrate critical thinking skills, problem-solving abilities, effective communication skills, and time management skills. Must demonstrate ability to work effectively independently and in an interdisciplinary team format.

PREFERRED QUALIFICATIONS

Previous experience with behavioral health utilization management.

Additional related education and/or experience preferred.

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EEO/Female/Minority/Disability/Veterans

Our organization supports a drug-free work environment.

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