Utilization Management Specialist - Remote

Opportunities at Optum, in strategic partnership with Allina Health. As an Optum employee, you will provide support to the Allina Health account. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

The Utilization Management Specialist collaborates with the care team to confirm the level of care and authorization for services. Reviews medical records and prepares clinical reviews for medical necessity and authorization. Is also responsible for facilitating the denial and appeal process.    

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. 
  

Primary Responsibilities: 
 
Ensures the appropriate mental health/behavioral health and addiction services are medically necessary and at the appropriate level of care per health plan benefits and patient care needs.

• Assesses clinical data from medical records to assure appropriateness of patient's admission
• Utilizes screening criteria to determine patient status
• Assures the medical record has the proper physician order and/or clinical documentation
• Monitors continued stay to identify potential issues and communicates results and opportunities to Allina Health System Behavioral Mental Health and Addiction Services Department staff, leadership, physicians and case manager.
• Evaluates potential denials or payment issues and initiates communication with physician or clinician regarding next steps
• Prepares and facilitates appeals for denied claims
• Facilitates peer to peer requests between admitting, attending physician, and the payer physician
• Other duties as assigned
    
  You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. 

• Licensed Social Worker – Minnesota Board of Social Work, or Licensed Marriage and Family Therapist- Minnesota Board of Family Therapy, or Licensed Professional Clinical Counselor- Minnesota Board of Behavioral Health and Therapy, or Registered Nurse- Minnesota Board of Nursing.  All licensure in good standing, unrestricted
• 2+ years of experience direct care experience in an acute hospital behavioral health/mental health setting, or free-standing treatment center
• 1+ years of experience using diagnostic and statistical manual (DSM) documentation standards

• Dual Licensure with one of the required licensures and a Licensed Alcohol and Drug Counselor – LADC- Minnesota Board of Behavioral Health and Therapy in good standing/unrestricted
• 2+ years of Mental Health and Addiction care management, and/or Utilization Management experience within an acute hospital system or insurance/managed care organization
• Epic Experience
• Knowledgeable in American Society of Addiction Medicine (ASAM) and substance abuse levels of treatment