Managed Care Specialist - Health Alliance Plan - Troy
General Summary:
To provide behavioral medicine utilization management, care/case management, disease management, population health management and autism interventions for inpatient and outpatient services to support the delivery of quality, cost effective health care services to our HAP membership across all product lines. The Manage Care Specialist will serve as a liaison between members and providers to facilitate achievement of optimal health for the member.
Principal Duties and Responsibilities
Performs all duties related utilization management, case management, disease management tasks to determine clinical appropriateness, assessing level of care requirements, length of stay such as InterQual criteria, HAP’s Benefit Administration Manual, Member’s Contracts, or Centers for Medicare & Medicaid Services (CMS) list appropriately for authorization requests. And recording all information in the case management platform software program.
Responds to and coordinates services for emergent or urgent requests in a timely and professional manner. Provides outreach, education, health coaching and motivational interviewing to members with behavioral health conditions. Perform face to face care management interventions (provider location-including but not limited to an inpatient hospital, physician’s office, community setting Coordinate and facilities discharge planning with member, care givers, inpatient hospital and outpatient providers Comprehensively assess the member’s goals as well as their physical, functional, psychological, social, environmental and financial status.
Develop, implement, monitor and modify a plan of care through an interdisciplinary and collaborative team process in communication with the member, the care givers and the health care team.
Effectively communicates with individuals, departments and other entities for timely resolution of the identified problems.
Adhere to all department, company and Health system policies and procedures, maintain current knowledge of HAP benefit levels product lines and operations, maintain current knowledge and efficacy with in all resources the company, such as all software programs relating to daily operation, onehap, SharePoint, hap.org, yammer, etc.
Perform after hour duties like duties during regular business as needed during the week and as schedule for weekend coverage and of holiday coverage to meet compliance expectations. On-call and overtime for after-hours case management and/or urgent requests as needed.
Participate in multi-disciplinary Continuous Improvement workgroups for the development and operational process improvement activities. Adheres to NCQA, CMS, DOL and ERISA regulatory requirements addressing and documentation of issues related utilization management, case management with in the care management platform software.
Assist in the implementation of NCQA standards HEDIS initiatives and adheres to regulatory requirements and processing timeframes
Participates in Special projects when assigned as needed
Perform other related duties as assigned
Education Required:
Master’s degree or Doctorate in Behavioral Medicine discipline from an accredited college or university in a nationally recognized behavioral health field.
Certifications/Licensures Required:
A current, valid Michigan license to practice without any conditions, limitations or restrictions:
License Master of Social Worker, Limited Licensed Psychologist, Fully Licensed Psychologist, Licensed Professional Counseling
Board Certified Behavioral Analyst (if applicable)
Experience Required:
Minimum of five (5) years’ experience in clinical setting for Mental health and Chemical Dependency and/or Applied Behavioral Analysis. Preferably additional disease management and/or managed care experience, management of patients in an ambulatory/crisis intervention setting or EAP setting. And or Applied Behavioral Analysis therapy if applicable
Experience Preferred:
Knowledgeable about Medicaid and Dual Eligible programs
Skills and Abilities:
Demonstrated excellence in writing and composition skills with the ability to express thoughts in clear written form. Knowledge of DSM V and ICD CPT coding and medical necessity criteria
Must work effectively with persons of varying position levels and diverse interests to reach consensus on resolutions of problems.
Must be able to effectively engage members in all management programs.
Ability to perform accurate and timely documentation and to assimilate summary and outcome data.
Ability and manual dexterity to master all the equipment. Working knowledge of compute, facsimile, telephone, digital paper, voice mail and copy machines
Ability to utilize supervision effectively.
Excellent verbal communication skills.
Excellent problem solving skills.
Ability to work autonomously and as a member of a team.
Knowledge of behavioral medicine disease states.
Knowledge of National Council on Quality Assurance (NCQA) standards and HEDIS (Healthcare Effectiveness Data and Information Set) behavioral health measures.
Superior working knowledge of computer functioning including Adobe, Word, Excel and other Microsoft Office programs.
Working knowledge of Internet search functions for research and investigational purposes.
Knowledge of managed care principles for Mental Health and Chemical dependency.
An understanding of appropriate alternatives in the management of patients needing Mental Health and Chemical dependency services
Interest in creative approaches to treatment.
Excellent organizational skills, including use of time management principle to accomplished priorities effectively and high quality.
Overview
Henry Ford Health System, one of the largest and most comprehensive integrated U.S. health
care systems, is a national leader in clinical care, research and education. The system includes
the 1,200-member Henry Ford Medical Group, five hospitals, Health Alliance Plan (a health
insurance and wellness company), Henry Ford Physician Network, a 150-site ambulatory
network and many other health-related entities throughout southeast Michigan, providing a
full continuum of care. In 2015, Henry Ford provided $299 million in uncompensated care.
The health system also is a major economic driver in Michigan and employs more than 24,600
employees. Henry Ford is a 2011Malcolm Baldrige National Quality Award recipient. The
health system is led by President and CEO Wright Lassiter III. To learn more, visit HenryFord.com.
Benefits
Whether it's offering a new medical option, helping you make healthier lifestyle choices or
making the employee enrollment selection experience easier, it's all about choice. Henry
Ford Health System has a new approach for its employee benefits program - My Choice
Rewards. My Choice Rewards is a program as diverse as the people it serves. There are
dozens of options for all of our employees including compensation, benefits, work/life balance
and learning - options that enhance your career and add value to your personal life. As an
employee you are provided access to Retirement Programs, an Employee Assistance Program
(Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness
and access to day care services at Bright Horizons Midtown Detroit, and a whole host of other
benefits and services.
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health System is
committed to the hiring, advancement and fair treatment of all individuals without regard to
race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,
weight, marital status, family status, gender identity, sexual orientation, and genetic information,
or any other protected status in accordance with applicable federal and state laws.