PRINCIPAL RESPONSIBILITIES:

The BH Case Management (CM) Navigator will assist with case management and utilization management of services and monitor continuously for quality and accuracy.

This role is responsible for processing and monitoring the authorization process and corresponding documentation. The BH CM Navigator will support the CM BH RN and UM LCSW through completion of the administrative components of Case/Disease management (authorizations, basic care coordination) and Utilization Management (concurrent, urgent and routine pre-service, as well as retrospective authorizations).

This position exercises considerable discretion and independent judgment in the performance of duties and responsibilities. This position works under the direct supervision of the Sr. Director of Behavioral Health and will assist in the operational delivery of the plan’s BH related case management and care coordination programs and processes.

The BH Case Management Navigator will be working closely with a team comprised of the BH UM Triage Staff, BH CM Nurse, CM Complex Case Manager Nurse, a Medical Social Worker and a Health Navigator. This collaborate team approach to case management will include key departments at the health plan, including Case Management and Utilization. Externally, the position will interact with delegates contracted organizations and providers, health networks, and other stakeholders in a manner that promotes collaborative working relationships.

Principal responsibilities include:

• Perform the primary functions of assessment, planning, facilitation and advocacy through collaboration with the member and other health care resources involved in the member’s care.
• Work closely with licensed and unlicensed staff to co-manage the care of complex cases telephonically through regular contact with members, caretakers, healthcare professionals and others involved in the member’s care.
• Communicate and coordinate with PCPs, specialists, hospitals, other providers, and internally.

ESSENTIAL FUNCTIONS OF THE JOB:

• Communicate with providers, members, and community resources as necessary, to support the planning, implementation and evaluation of care management programs.
• Works closely with Member Services to coordinate member access to timely and appropriate care
• Work closely with licensed and unlicensed staff to co-manage tasks with individual members and navigate complex patients with mental health disease to access care
• Works with licensed staff to support the planning, implementation and evaluation of members with BHT/ABA and behavioral health disease
• Communicate effectively, both verbally and in writing
• Works to clarify issues regarding a member status, needs, and goals
• Work with the Senior Director of BH, Senior Medical Director and clinical staff as well as other departments at the Alliance to receive, date, document and resolve Behavioral Health related inquiries/issues for claims, authorizations, appeals and eligibility. Perform these duties in a professional and timely matter.
• Accurately interpret and communicate member benefits and serve as resource for nurses and the IT Department in verifying and resolving member eligibility.
• Complete other duties and special projects as assigned.
• Multi-task and prioritize.
• Provide administrative support.

• Perform writing, administration, and data entry into multiple systems.
• Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS:

• Constant and close visual work at desk or computer.
• Constant sitting and working at desk.
• Extensive typing using keyboard and/or mouse.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders, files, binders, and other objects weighing between 0 and 30 lbs.
• Frequent walking and standing.
• Occasional driving of automobiles.

Number of Employees Supervised: 0

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• Bachelor’s degree or equivalent work experience required. Academic major in health services or related field preferred.

SUBSTITUTION FOR ACADEMIC MAJOR:

• Year over year full time experience may be substituted for the academic major (up to 4 years) when administrative duties are performed in a health service agency or program.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• One year experience in managed care or health care setting preferred.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Strong verbal and written communication skills.
• Ability to work within guidelines and protocols to achieve decisions independently.
• Critical thinking and problem-solving skills.
• Ability to work in cooperation with others.
• Ability to prioritize multiple projects as well as work for several other employees.
• Ability to act as resource to department staff.
• Working ability with Microsoft Office suite.

SALARY RANGE $33.46-$50.20 PER HOUR

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.