This position gathers and synthesizes clinical information in order to authorize services. Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity criteria. Collects and analyzes utilization information. Assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity. Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria. Performs independent reviews on children/adolescents who are in the care and custody of the State of Florida and residing in a therapeutic group home level of care.

• Conducts an independent review of children/adolescents who are residing in a therapeutic group home level of care at 60 days post admission and then every 90 days thereafter. The focus of the review is on the child/adolescent's progress towards achieving the goals and objectives of the treatment plan.


• Reviews medical records, placement documentation, treatment plans and progress notes.


• Completes Child/adolescent clinical interview via telehealth.


• Interviews collateral contacts.


• Completes Child and Adolescent Strengths and Needs (CANS) assessment.


• Completes a summary of findings report pursuant to F.S. 39.407 while addressing the following: 1.) The child appears to have an emotional disturbance serious enough to require residential treatment and is reasonably likely to benefit from treatment. 2.) The child has been provided with a clinically appropriate explanation of the nature and purpose of the treatment. 3.) All available treatment options less restrictive than residential treatment have been considered and a less restrictive alternative that would offer comparable benefits to the child is unavailable.


• Makes themselves available to answer questions from the Department, or their designee, the Guardian ad-Litem, and the Medicaid health plan that is financially responsible for the child's care in treatment.


• Interacts with providers in a professional, respectful manner.


• Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria.


• Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network.


• As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms.


• Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and policies, procedures and criteria.


• Develops and manages new enrollee transitions and those involving a change in provider relationships.


• Develops and implements transition plans, as indicated, to ensure continuity of care.


• Negotiates and documents single case agreements according to procedures.


• In conjunction with providers and facilities, identifies, develops and monitors discharge plans.


• Collaborates with the Care Coordination team to implement support for transitions in care.


• Facilitates timely sharing of enrollees' clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care.


• Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases.


• Assures that case documentation for each decision is complete, including related correspondence.


• Participates in Care Coordination team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.


• Maintains an active work load in accordance with performance standards.


• Works with community agencies as appropriate.


• Participates in network development including identification and recruitment of quality providers as needed.


• Advocates for the enrollee to ensure health care needs are met.


• Interacts with providers in a professional, respectful manner.


• Provides coverage of Nurse Line and/or Crisis Line as requested or required for position.
  
  

Responsibilities
Masters level licensed behavioral health professional.
Good organization, time management and verbal and written communication skills.
Ability to function independently.
Knowledge of ICD and DSM IV coding or most current edition.
Ability to use computer systems.
Mental health counselor licensed under chapter 491 who has at least 2 years of experience in the diagnosis and treatment of serious emotional or behavioral disturbance in children and adolescents and who has no actual or perceived conflict of interest with any residential treatment center or program.
RN or clinical credentials in a behavioral health field. If not an RN, must hold Masters or Doctoral Degree. If nurse, RNlicense at a minimum. If other than RN, Masters level licensed behavioral health professional.
Good organization, time management and verbal and written communication skills.
Knowledge of utilization management procedures, Medicaid benefits, community resources and providers.
Knowledge and experience in diverse patient care settings including inpatient care.
Ability to function independently and as a team member.
Knowledge of ICD and DSM IV coding or most current edition.
Ability to analyze specific utilization problems and creatively plan and implement solutions.
Ability to use computer systems.
2 or more years of experience post degree in a clinical, psychiatric and/or substance abuse health care setting.
Requires minimum of 2 years of experience conducting utilization management according to medical necessity criteria.

General Job Information

Title
Qualified Evaluator- Wyoming

Grade
24

Work Experience - Required
Clinical

Work Experience - Preferred

Education - Required
Associate - Nursing, Master's - Behavioral Health

Education - Preferred

License and Certifications - Required
LCSW - Licensed Clinical Social Worker - Care Mgmt, LPC - Licensed Professional Counselor - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt

License and Certifications - Preferred

Salary Range

Salary Minimum:
$58,440
Salary Maximum:
$93,500

This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.

This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing.

Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.