Behavioral Hlth Care ManagerI - LMHC,LCSW,RN,MFT (Richmond, VA) - 54744VMJ

Behavioral Hlth Care ManagerI - LMHC,LCSW,RN,MFT (Richmond, VA) - 54744VMJ

WellPoint is the nation's leading health benefits company serving the needs of approximately 28 million medical members nationwide.

The Behavioral Health Care Manager is responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy, clinical criteria, and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Primary duties may include, but are not limited to: Conducts pre-certification, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Ensures member access to medically necessary, quality healthcare in a cost effective setting according to contract. Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process. Collaborates with providers to assess members needs for early identification of and proactive planning for discharge planning. Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications. Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.



Requirements:

Requires a current unrestricted Commonwealth of Virginia RN, LCSW, LPC, LMHC or MFT license and at least 2 years of direct psychiatric and/or substance abuse experience or any combination of experience which would provide an equivalent background. Current or previous experience in Utilization Review/Case Management strongly preferred.