LOCATION: Remote – This is a home based, virtual position that operates Monday – Friday from 8:30am-5:00pm EST. This person must reside in North Carolina or within 40 miles of the NC border.
GENERAL STATEMENT OF JOB
The IDD UM Clinician provides multiple utilization review tasks, including review of service plans and authorization of clinically appropriate services. The IDD UM Clinician works with Care Coordinators and service providers to facilitate appropriate service planning and service provision. As needed, the IDD UM Clinician also conducts post service reviews of services to determine the appropriateness of series provided. Additionally, the IDD UM Clinician will provide other clinical reviews, case consultations and training in order to facilitate the provisions of clinically appropriate services to consumers with intellectual and developmental disabilities.
ESSENTIAL JOB FUNCTIONS
Review Person Centered Plans and Other Service Plans:
- Review plans submitted by providers with authorization requests
- Where plans do not meet established standards for medical necessity, provide feedback and request additional information from providers, including consultation and education as appropriate.
- Render authorization determinations
- Authorize requested services meeting authorization requirements
- Complete and send Educational Notifications for requests not meeting sufficient information and other administrative requirements.
- Refer service requests for medical necessity determinations to a Clinical Peer when medical necessity is not established.
- Ensure complete documentation of review and determinations
Conduct Post Service Reviews and Other Reviews of Services Provided:
- Participate in planned reviews of services provided to determine the appropriateness of services provided
- Respond to al hoc requests for special reviews of services
- As requested, participate in complaint investigations, local monitoring reviews, endorsement reviews, and other quality of care reviews
Facilitate Development of the Provider Network:
- Identify and document service gaps and deficiencies in access to services
- Consult with and educate providers about Vaya service authorization requirements, evidence based practices and other components to quality service provision
- Identify provider training needs; provide training as needed and requested
- Provide consultation to providers as requested regarding difficult and high-risk cases
- Collaborate with Vaya Care Coordination staff to improve services to high risk consumers and those without a Clinical Home
Other duties as assigned.
KNOWLEDGE, SKILLS, & ABILITIES
- A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance. This will require exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts. Problem solving, negotiation, arbitration and conflict resolution skills are essential to balance the needs of both internal and external customers.
- Mastery of utilization review principles to ensure continuity of care and clinical evaluations as needed for appropriate provision of intensive, crisis services and other levels of care.
- Knowledge of prior authorization review, continued stay and discharge reviews for IDD services to ensure appropriate service intensity and level of care for consumer.
- Knowledge of documentation and clinical protocols for utilization purposes.
- Knowledge of linkage, authorization and level of care determinations, assisting providers with creative problem solving to suggest alternative approaches to care.
- Clinical knowledge of managed systems of IDD. Knowledge of managed behavioral care practices and principles in order to provide UR.
- Ability to collaborate with providers and other agencies.
- Clinical knowledge of intellectual and developmental disabilities as a basis for clinical reviews and decisions for authorization.
- Comprehensive knowledge of resources and the ability to use a personal workstation. Knowledge of database and data entry is essential.
EDUCATION & EXPERIENCE REQUIREMENTS
Master’s degree in Special Education, Psychology, Social Work or closely related Human Services field OR current licensure as an RN is required. Must have:
- Two (2) years of experience in a Utilization Management environment in Behavioral Healthcare is required for this role.
- At least two (2) years of post-degree progressive experience and practice that is relevant to the clinical area (IDD) for the which they will be conducting the initial clinical review
Must meet the criteria of being a North Carolina Qualified Professional with the population served (IDD) in 10A NCAC 27G .0104
Licensure/Certification Required:
- Individuals who conduct initial clinical reviews must possess a current, active, unrestricted professional license or certification from North Carolina in a Human Services field. For incumbents who meet the requirements of this role through a degree in Nursing, incumbents must also possess a current, active Nursing License from the NC Board of Nursing or Nursing Licensure Compact (NLC). For incumbents who meet the requirements of this role through being a Master’s Level Human Services Professional, incumbent must also possess a current, active, unrestricted professional license in psychology, counseling, marriage and family therapy, additions, or similar (examples include LCMHC, LCSW, LMFT, LPA).
PHYSICAL REQUIREMENTS
- Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
- Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
- Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
- Mental concentration is required in all aspects of work.
RESIDENCY REQUIREMENTS: The person in this position is required to reside in North Carolina or within 40 miles of the NC border.
SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.
DEADLINE FOR APPLICATION: Open Until Filled
APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.
Vaya Health is an equal opportunity employer.
Skills Required
- Master's degree in Special Education, Psychology, Social Work or closely related Human Services field OR current licensure as an RN
- Two (2) years of experience in a Utilization Management environment in Behavioral Healthcare
- Two (2) years of post-degree progressive experience relevant to IDD clinical area
- Current, active, unrestricted professional license in a Human Services field from North Carolina
What We Do
Vaya Health is whole-person health organization helping those with behavioral health and intellectual or developmental disabilities connect with the right providers on their journey toward healing, recovery and hope. At Vaya Health, our goal is to embrace innovation, adapt to a changing environment and maximize resources for the long-term benefit of the people and communities we serve. We maintain a network of highly qualified providers, respond to individual and family needs on a local level and effectively manage public service dollars. Additionally, through a robust public outreach program, we educate the community about mental health, substance use disorder and I/DD issues and available services — individuals in need can speak with a representative any time. Through reinvestment initiatives, we are demonstrating every day how public managed care can benefit both the people who receive our services and the taxpayers of North Carolina. Every day, we work with each other, our providers, our partners and the people we serve to develop the best and most-needed services for a healthier North Carolina.
