Job Summary:

Ensure consistent application and management of Kaiser Permanente mental health and chemical dependency benefits.

Essential Responsibilities:

Benefit payment authorizations. Manage behavioral health benefits by providing medical necessity determinations. Medical necessity determinations are completed by gathering the most current clinical information from the assessing/treating provider and applying the approved Kaiser Permanente medical necessity criteria to determine what can be authorized within the benefit provisions. Medical necessity criteria are used for all pre-authorization, concurrent review and post-service requests. Authorizations must be for the most clinically appropriate, least restrictive, most cost effective and within standards of care to safely treat the member.

Member contact. Member contact may occur for a variety of reasons which can include benefit explanations, resource identification and appointment scheduling.

Payment denials. Kaiser policies are followed for all benefit payment denials. UM coordinator is always available to explain a payment denial to providers and members.

Consultations. Consultations are provided to internal and external providers regarding medical necessity interpretation, benefits, covered services, contracted providers and available resources that meet the clinical needs of the Kaiser member.

Fraud and abuse. Responsibility for ensuring the appropriate expenditure of healthcare dollars in accordance with rules and regulations set forth in Kaiser policies, licensing and credentialing entities and all state and federal laws and regulations.

Ensuring continuity of care by facilitating communication between service providers regarding treatment planning, intervention, outcomes, and recommendations.

Care coordination. Ensuring upon discharge from higher levels of care that all members have an appropriate discharge plan within HEIDIS guidelines.

On-call rotation as assigned to cover pre-authorizations for non-business hours.

Specialist, Utilization Management-Mental Health (Remote - Must live in Oregon)

Job Description