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Job Summary
The Behavioral Health (BH) Care Management Coordinator primary responsibility is to evaluate a member’s BH condition through the review of medical records (including medical history and treatment records) to determine the medical necessity for patient’s services based on advanced knowledge and independent analysis of those medical records and application of appropriate medical necessity criteria. If necessary, the BH Care Management Coordinator directly interact with providers to obtain additional BH information. The BH Care Management Coordinator has the authority to commit the company financially by independently authorizing services determined to be medically necessary based on their personal review. For those cases that do not meet established criteria, the BH Care Management Coordinator provides relevant information regarding members BH condition to the Medical Director for their further review and evaluation. The BH Care Management Coordinator has the authority to approve but cannot deny the care for patients. The BH Care Management Coordinator is also responsible for maintaining regulatory compliance with federal, state and accreditation regulations. Additionally, the BH Care Management Coordinator acts a patient advocate and a resource for members when accessing and navigating the behavioral health care system.
Key Responsibilities
§ Note: InterQual - It is the policy of the Medical Affairs Utilization Management (UM) Department to use InterQual (IQ) criteria for the case review process when required. IQ criteria are objective clinical statements that assist in determining the medical appropriateness of a proposed intervention which is a combination of evidence-based standards of care, current practices, and consensus from licensed specialists and/or primary care physicians. IQ criteria are used as a screening tool to support a clinical rationale for decision making.
Education/License:
LCSW, LSW, LMFT or LPC or Active PA Licensed RN, BSN Preferred
Experience
Minimum of three (3) years of Behavioral Health clinical experience in a hospital or other health care setting. Prior Behavioral Health utilization management experience is desirable.
Medical management/precertification experience preferred.
Knowledge, & Skills
§ Oriented in current trends of medical practice.
Independence Blue Cross (IBC) provides health insurance and related services to some 2.2 million members in southeastern Pennsylvania and, through its subsidiaries, to more than 3 million people nationwide. The company's plans include Personal Cho...
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