At Vantage Health Plan, Inc. , we specialize in taking care of people: our members, our patients, and our employees. We offer competitive salaries and great benefits! Benefits include: Health, Dental, Life, Accidental Death and Dismemberment, Long Term Disability, Paid Time Off, and 401(k).
Job Summary: The Integrated Care Specialist will assist in all areas of the Integrated Care Department to achieve the common goal of improving quality of care within the Vantage Health Plan/Affinity Health Group population through case management and behavioral health utilization review. The Behavioral Health Utilization Management Program of Vantage Health Plan assures the delivery of medically necessary, quality patient care through appropriate utilization of resources in a cost effective and timely manner. The Integrated Care Specialist is an intricate part of this program by utilizing Vantage’s authorization system to review and approve services based upon Standardized Criteria, Health Plan Medical Policy, InterQual, and Clinical Guidelines and the local delivery systems. Each request for service is authorized in accordance with the member’s health plan benefits and mandates from regulatory agencies.
Essential Duties & Responsibilities:
• Perform initial intake, review and notification of decisions for authorization of services.
• Enter appropriate information for each authorization including diagnosis codes, procedure codes, and request types into Vantage’s authorization system.
• Obtain clinical information necessary to perform a thorough review of the request for services.
• Apply standardized criteria to each request and may approve requests for services, if appropriate.
• Work with provider’s office staff, physicians, and members to coordinate approval of services or provides detailed explanations of reasons for denial of services or alternate services recommended.
• Perform retrospective reviews, as appropriate, for authorization of procedures and services
• Process and resolve behavioral health appeals, grievances, coverage determinations, and claims questions
• Proactive telephonic outreach to Vantage Health Plan members to engage participation in behavioral health care management programs offered by the department
• Assess members with behavioral health issues to evaluate current health status, history of behavioral health treatment, resource needs and compliance
• Actively participate in all enrollment activities
• Complete psychological, emotional and environmental assessments for providing appropriate, timely interventions to ensure provision of optimal care
• Work collaboratively with other members of the Interdisciplinary team-to include: Vantage Case Managers, Social Services, Field Care Managers, Transitional Care, the member’s Provider(s), and the Behavioral Health Utilization Review team
• Monitor member for compliance with medications and appointments
• Educate family and caregivers on behavioral health disease process
• Coordinate care with PCP, psychiatrist, therapist, home health provider, community resources, etc.
• Track member’s progress including frequency of hospitalizations and admissions to outpatient services
• Understand clinical program design, implementation, documentation and reporting
• Comply with performance and reporting standards as defined by Vantage Health Plan
• Assist in developing policies and procedure for utilization review and integrated care activities
• May be assigned extracurricular activities, which could include underwriting, subrogation, reimbursement authorizations, maintaining provider portals, appeals, reinsurance, bed days, training, quality review, claims processing queues and special projects
• Other duties as assigned
Knowledge, Skills, and Abilities:
• Active RN, LPN, MSW, and /or LPC license in good standing with the state of Louisiana or degree in counseling, substance abuse, or related behavioral health field
• Previous experience in utilization review, case management, and/or medical underwriting
• Experience in corporate office setting preferred
• Proficient in Microsoft Office Suite (Excel, Word, Power Point, etc.)
• Ability to type minimum of 40 WPM preferred
• Highly organized and efficient with strong attention to detail
• Ability to multitask and prioritize in a fast-paced, ever-evolving environment
• Excellent verbal and written communication skills
• Customer service-oriented attitude/behavior
• Ability to work with limited supervision and to make decisions based on established policies and procedures
• Ability to interact effectively with all levels of staff
• This position has no supervisory responsibilities
• Works under general supervision of the Director of Integrated Care
• This position operates in a professional office environment with opportunity to work from home upon meeting training, eligibility, technical, and performance requirements as deemed appropriate by management
• This is a full-time position (40 hours/week)
• Overtime may be required
• Occasional weekend on-call may be required
• Travel may be required
The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable qualified individuals with disabilities to satisfactorily perform these essential functions without causing an undue hardship for the employer.
While performing the duties of this job, the employee is required to remain in a stationary position for long periods of time and must frequently move about the office. The employee must constantly operate a computer and other office equipment such as phones, keyboards, printers, and copiers. The employee is regularly required to communicate with others via phone, email, etc. Occasionally, the employee is required to move up to 10 pounds and may, at times, be required to move up to 50 pounds.