About this role
Department Name
Work Shift
Day
Job Category
Clinical Care
The future is full of possibilities. At Banner Health, we’re excited about what the future holds for health care. That’s why we’re changing the industry to make the experience the best it can be. If you’re ready to change lives, we want to hear from you!
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.
Banner Plans & Networks (BPN) is an integrated network for Medicare and private health plans. Known nationally as an innovative leader, BPN insurance plans and physicians work collaboratively to keep members in optimal health while reducing costs. Supporting our members and vast network of providers is a team of professionals known for innovation, collaboration, and teamwork. If you would like to contribute to this leading-edge work, we invite you to bring your experience and skills to BPN.
As a Behavioral Health Utilization Care Manager, you will review prior authorization requests for outpatient behavioral health services, ensuring medical necessity and alignment with clinical guidelines and health plan requirements. You will collaborate with providers and interdisciplinary teams to support timely care decisions and participate in team initiatives as prior authorization programs continue to expand. The ideal candidate will have experience in outpatient behavioral health, community mental health, and Applied Behavior Analysis (ABA), with a strong understanding of the Arizona behavioral health landscape and established relationships within the local provider community.
Your work schedule will be Monday-Friday primarily 8:00 a.m.- 5:00 p.m. Arizona Time Zone. Your work location will be entirely remote. This position does require Arizona residency for compliance. If this role sounds like the one for you, 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.
Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Banner Health with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.
NOTE: The core functions are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Specific tasks or responsibilities will be documented as outlined by the incumbent's immediate manager.
SUPERVISORY RESPONSIBILITIES
DIRECTLY REPORTING
None
MATRIX OR INDIRECT REPORTING
None
TYPE OF SUPERVISORY RESPONSIBILITIES
None
Banner Health Leadership will strive to uphold the mission, values, and purpose of the organization. They will serve as role models for staff and act in a people-centered, service excellence-focused, and results-oriented manner.
PHYSICAL DEMANDS/ENVIRONMENT FACTORS
OE - Typical Office Environment: (Accountant, Administrative Assistant, Consultant, Program Manager)
Requires extensive sitting with periodic standing and walking.
May be required to lift up to 20 pounds.
Requires significant use of personal computer, phone and general office equipment.
Needs adequate visual acuity, ability to grasp and handle objects.
Needs ability to communicate effectively through reading, writing, and speaking in person or on telephone.
May require off-site travel.
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.
DATE APPROVED 11/03/2019
Estimated Pay Range
$28.28 - $47.13 / hour
Banner Health is committed to pay equity and transparency. The posted compensation range is a reasonable estimate that extends from the lowest to the highest pay Banner Health in good faith believes it might pay for this particular job, based on the circumstances at the time of posting.
This range is based on possible base salaries and does not include the value of our total rewards package. Actual pay determined at offer will be based on years of relevant work experience, education, certifications, skills, and geographic location, along with a review of current employees in similar roles to ensure pay equity is achieved and maintained.
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