Behavioral Health Medical Management Specialist
The Medical Management Specialist is responsible for completing prior authorization and concurrent reviews for behavioral health services by uutilizing pre-approved criteria and guidelines to validate medical necessity. Medical Management Specialist also reviews appropriateness of discharge planning; coordinates discharge planning with outpatient providers; issues Notices of Actions and participates in clinical rounds.
- Conducts prior authorization and concurrent reviews.
- Assessment of post discharge needs and coordinates of services.
- Refers members to care management and disease management programs.
- Completes Notices of Action or Notices of Decision and maintains accurate clinical documentation of authorizations, case management, concurrent review and discharge.
- Serves as subject matter expert for behavioral health services, and as a resource for program specialist, including cultural appropriateness. Provides support and technical assistance to HCA and HCA network of care providers based on the needs of the members or of a specific provider
- Consults with Medical Director as needed to review complex cases
Education / Experience / Other Requirements
Years of Experience:
Skills & Abilities:
• Strong interpersonal skills.
• Critical thinking, ability to make independent decisions and refer to others as necessary.
• Understanding of medical records and UR systems.
• Ability to type 35 word per minute.
• Excellent computer skills navigating various systems/platforms and skills using Microsoft Office Suite
• Excellent writing and documentation skills and customer service.