Utilizing key principles of utilization management, the Behavioral Health Utilization Management Specialist will perform prospective, concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage. Leveraging clinical expertise and critical thinking skills, the Behavioral Health Utilization Management Specialist, will analyze clinical information, contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements contribute to determination of appropriateness and authorization of clinical services both medical and behavioral health.

ESSENTIAL FUNCTIONS:
-- 50% Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, CareFirst Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all CareFirst lines of business to include Commercial, FEP, and Medicare primary and secondary policies.
-- 30% Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts to assist with benefit determination.
-- 20% Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care. Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.

Required Skills

Certifications (one or both):
(1) LCPC - Licensed Clinical Professional Counselor - MD, DC, or VA license required
(2) LCSW-C - Licensed Clinical Social Worker - MD, DC, or VA license required

Required Education: Education Level: Master-s Degree. Education Details: Psychology or Social Work

Experience:
- 5 years Clinical experience required
- 2 years Care Management preferred
- Working knowledge of managed care and behavioral health delivery systems.
- Experience in direct treatment of both substance use and mental health focused treatment.
- Excellent MS Excel Skills
- GuidingCare or similar utilization platform tool
- Milliman Care Guidelines and Apollo Guidelines is required.
- ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references is required