Excellus Health Plan Inc.
BH Member Treatment Coordinator I/II/III - 21007 (Safety Net) (Biotech)
Summary
The Member Treatment Coordinator (MTC) is responsible for coordinating, integrating and monitoring the use of behavioral health services in accordance with departmental, corporate, state, federal, accreditation standards, as well as CMS standards if appropriate to the case. This position is a blend of Utilization Management and Case Management with high level provider interface. The MTC assists, supports, advocates, and educates the members, family, providers, and employer groups through a continuum of care. The Coordinator delivers efficient, effective and seamless care to members.
Essential Responsibilities/Accountabilities
All Levels
• Performs clinical review of the appropriateness and quality of behavioral health services, applying guidelines and medical policies.
• Performs a clinical assessment and coordinates care on all members discharged from a behavioral health inpatient level of care and assists members in accessing the most appropriate next level of care.
• Carries out job responsibilities in accordance with departmental, corporate, state, federal and accreditation standards.
• Plans, implements, and documents utilization management activities which incorporate a thorough understanding of clinical knowledge, members' specific health plan benefits, and efficient care delivery processes. Ensures compliance with policy and procedure. Identifies and refers potential quality of care and utilization issues to Health Plan medical director.
• Utilizes appropriate communication techniques with members and providers to obtain behavioral health information, assesses need for continuation of services, assists members in obtaining needed services, as appropriate, interacts with the treating physician or other providers of care.
• Works in collaboration with members' physicians and other health care providers to assess the needs of the member, facilitate development of an interdisciplinary plan of care, coordinates services, evaluates effectiveness of services and modifies the member plan of care as necessary.
• Acts as a resource to the provider community, explaining processes for accessing Health Plan to perform clinical review identifying appropriate community resources, or otherwise interacts with Health Plan programs and services.
• Provides appropriate resources and assistance to members with regards to managing their health care across the continuum of care.
• Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services. As necessary, will provide assistance to Claims and/or Customer Service Departments with the definition of medical terms, including diagnosis and procedures, as related to benefit or coverage issues.
• Measurement of job performance includes meeting established corporate and department standards in terms of volume and accuracy as measured by audit.
• Interacts with members, providers, families and internal customers in scheduling patient treatments or other procedures.
• Evaluates the effectiveness of treatment(s) and accuracy of diagnosis. Modifies plan and diagnosis, as necessary.
• Maintains current and accurate records for statistics, cost effectiveness, admissions and discharge plans
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and Leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
Level II – similar responsibilities for level I, in addition to the following:
• Offers process improvement suggestions and participates in the solutions of more complex issues/activities.
• Mentors junior staff & assists with coaching whenever necessary.
• Provides consistent positive results of audits.
• Works independently in coordinating and collaborating with members and providers, resulting in improving member and community health.
• Manages more complex assignments; larger caseloads and a greater number of facilities.
• Displays leadership and serves as a positive role model to others in the department.
Level III - similar responsibilities for level I, in addition to the following:
• Audit - Ensures regulatory requirements such as DOH, CMS and Medicaid, and, accreditation requirements such as NCQA, URAC and HEDIS functionalities of behavioral health services relative to patient care are met or exceeded across all lines of business in the day to day work. Serves as internal auditor within the group.
• Process Management and Documentation –
o Identifies, recommends and assesses new processes as necessary to improve productivity and gain efficiencies.
o Assists in updated departmental policies, procedures and desk-top manuals relative to the functions
o Identifies and develops processes and guidelines for performance improvement opportunities for the Behavioral Health Department.
• Expert and resource for escalations - Serves as subject matter expert and if called upon, works directly with the operation and clinical staff to resolve issues and escalated problems.
• Liaison role –
o Acts as the liaison point person for activity generated by CAU, CS, PR, Sales & Marketing and Monroe Plan.
o Primary liaison between the Behavioral Health Member Treatment. department and other functional areas.
• Mentor (to others in department) - Provides guidance and leadership to the daily activities of the Behavioral Health Department clinical staff. Acts as resource to Behavioral Health staff, members and providers.
• Provides backup for the Team Leader, whenever necessary. Participates in the orientation of new staff and/training opportunities for all staff. Assists staff to identify opportunities to successfully engage members into care.
• Responsible for workflow coordination of the group.
• Assists Medical Director (MD) in projects at times.
• Responsible for all aspects of the behavioral health department functions including quality, productivity, utilization performance, ROI and educational needs to address established policies and procedures and job responsibilities.
Minimum Qualifications
NOTE:
We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.
All Levels
• RN with current New York State license (BSN Preferred) or a New York State Licensed Clinical Behavioral Health Professional - LMFT, LCSW, LMHC.
• Minimum of three years clinical experience (community health, behavioral health, and managed care experience preferred).
• Strong communication skills; written, writing and listening
• Must demonstrate proficient experience in use of a computer. Example-creating documents, Excel, Internet and/or email...
• Experience in interpreting health plan benefit plans preferred.
• Knowledge of Intermural criteria and/or Medicare guidelines preferred.
• Shows an understanding and works accordingly in order to meet the highest quality standards.
• Must demonstrate work habits sufficient to be able to work independently on a daily basis.
• Strong organizational skills required.
• Ability to independently travel throughout the Health Plan markets.
Level II – similar qualifications as level I, plus:
• Must have been in a current behavioral health position for at least 2 years. If the above is not met, however, transfer to this department either externally or internally should meet all the necessary functions of this level.
• Understanding and performing of the Utilizations Management aspects of the job.
• Deliver efficient, effective, and seamless care to members.
• Understands when to escalate to management.
• Be an expert in the technology of the job
• Ability to take on broader responsibilities
• Ability to participate in training of new staff
• Be part of committees and able to lead some committees
Level III - similar qualifications as level I & II, plus:
• Must have been in a current behavioral health position or similar subject expert for at least 5 years
• Broad understanding of multiple areas (i.e. UM and CM). At this level, incumbent is required to know multiple functional areas and supporting systems. (BREADTH)
• Expertise in Behavioral Health area and able to handle complex assignments, difficult members and highly visible issues. (DEPTH)
• Ability to lead the training of new staff.
• Demonstrated presentation skills.
Physical Requirements
Ability to travel, ability to work long hours on a computer
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The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.
Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.
OUR COMPANY CULTURE:
Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
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