UMUR Manager

Job Code: UMUR - 121
Revision Date: November 4, 2022

Starting Salary: $30.29 hourly; $62,993 annually
FLSA: Exempt

Overview

We are an agency committed to innovative behavioral health services in trauma-informed care that promote healing and recovery to instill a sense of empowerment and foster a lifelong sense of resilience.

General Description

The purpose of this job is to coordinate, implement, and manage the Utilization Management program which includes Prior Authorization, Utilization and Concurrent Review. The Utilization Management program collaborates with the Medicaid Managed Care companies, Medicare Advantage, and other third-party insurance companies and their providers. The UMUR Manager promotes the clinical quality and cost effectiveness of prior authorization and concurrent review functions. Also responsible for the evaluation of the appropriateness services and ensuring medical necessity is warranted, facilitates evidence-based criteria or guidelines, and under the provisions for the applicable health plan.

This class works independently, under limited supervision, reporting major activities through periodic meetings.

Duties and Responsibilities

The functions listed below are those that represent the majority of the time spent working in this position. Management may assign additional functions related to the type of work of the position as necessary.

• Supervises, directs, and evaluates assigned staff, processing employee concerns and problems, directing work, counseling, disciplining, and completing employee performance appraisals.
• Coordinates, assigns and reviews work and establishes work schedules; maintains standards; monitors status of work in progress; inspects completed work assignments; answers questions; gives advice and direction as needed.
• Conducts reviews using clinical information submitted by providers, direct contact with providers, review of medical persons with a serious mental illness.
• Manages the Adverse Determination/Medicaid Fair Hearing processes per outlined policy and procedure.
• Conducts utilization reviews and grant authorization decisions limited to continued stays, including overrides and add-on services, for individuals who are already receiving authorized services from EHN when the request is complete, accurate, and clearly falls within the DSHS UM Guidelines. Any requests for authorization that do not clearly meet the guidelines must be fully reviewed by the Utilization Manager.
• Submits authorization reports (overrides 60 day authorizations, underutilized, MFH, service utilization, monthly authorized uniform assessment count) as requested.
• Utilizes the Uniform Assessment Guidelines, Utilization Management Inpatient Admission Program and Plan for 3rd Party Payers.
• Participates in provider training on the UM process, monitors provider adherence to UM Guidelines and provides consultation when needed.
• Reviews data to detect outliers and unusual patterns of utilization and recommends interventions.
• Administers Behavioral Health benefits by performing precertification and concurrent reviews for inpatient hospitalization if applicable.
• Manages utilization data, ensure clinical documentation is provided for continued stay reviews, activities are non-duplicative, and utilization related data is being received, collected, and summarized.
• Performs other duties as assigned.

Minimum Education and Experience Requirements

Requires a Master's Degree in Psychology, Behavioral Health, Business, Nursing, or Public Administration supplemented by four (4) years of experience in behavioral health, hospital administration or closely related field; or possession of any equivalent combination of education, training, and experience which provides the requisite knowledge, skills, and abilities.

Experience with trauma-informed services; cognitive behavioral therapies, including DBT; and motivational therapies including the use of incentives, preferred.

Required Knowledge and Abilities

Knowledge of trauma-informed theories, principals, and practices (includes multi-faceted understanding of concepts such as community trauma, intergenerational and historical trauma, parallel processes, and universal precautions), preferred.

Physical Demands

Performs sedentary work that involves walking or standing some of the time and involves exerting up to 10 pounds of force on a regular and recurring basis or sustained keyboard operations.

Unavoidable Hazards (Work Environment)

Involves routine and frequent exposure to:

• Bright/dim light; Dusts and pollen.
• Other extreme hazards not listed above.

Special Certifications and Licenses

• Prefers RN, RN-APR, PA, PhD Psychologist, LPC, LCSW or similar licensing or certification.
• Must possess and maintain a valid state Driver's License with an acceptable driving record.
• Must be able to pass a TB, criminal background and drug screen.

Americans with Disabilities Act Compliance (ADA)

Emergence Health Network is an Equal Opportunity Employer. ADA requires Emergence Health Network to provide reasonable accommodations to qualified persons with disabilities. Prospective and current employees are encouraged to discuss ADA accommodations with management.

Other Job Characteristics

• Staffing requirements, including criteria that staff have diverse disciplinary backgrounds, have necessary State required license and accreditation, and are culturally and linguistically trained to serve the needs of the clinic's patient population.
• Credentialed, certified, and licensed professionals with adequate training in person-centered, family centered, trauma informed, culturally-competent and recovery-oriented care.
• Responsible for adhering to the EHN common purpose and service framework to continuously provide exceptional care to all constituents.

Note: This Class Description does not constitute an employment agreement between the Emergence Health Network and an employee and is subject to change by the Emergence Health Network as its needs change.