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• Monitors inpatient and/or outpatient mental health and substance abuse services to ensure medical necessity and treatment effectiveness.
• Provides telephone triage, crisis intervention, and emergency authorizations as assigned.
• Conducts concurrent reviews for inpatient, outpatient, and other levels of care based on scope of practice and experience.
• Collaborates with providers and facilities to develop and implement discharge plans.
• Performs quality clinical reviews and makes appropriate interventions to enhance member care.
• Educates and provides information to members and providers on behavioral health benefits, community resources, managed care programs, and company policies.
• Consults with Physician Advisors regarding clinical and authorization concerns.
• Participates in quality improvement activities including data collection, tracking, and analysis.
• Maintains an active caseload in alignment with National Care Manager performance standards.
• Coordinates with community agencies as appropriate.
• Suggests alternative treatment plans when service requests do not meet medical necessity criteria.
• Supports network development efforts by identifying and recruiting quality providers.
• Advocates for patients to ensure their treatment needs are met.
• Engages with providers in a professional and respectful manner to support the treatment process.

• Licensure is required and must meet State, Commonwealth, or customer-specific requirements.
• Acceptable licenses include: CEAP, LMSW, LCSW, LPC, RN, or LPN (with corresponding degrees).
• Minimum of 2 years’ post-degree experience in healthcare, behavioral health, psychiatric, and/or substance abuse settings.
• Strong organizational, time management, and communication skills.
• Knowledge of utilization management procedures.
• Familiarity with mental health and substance abuse community resources and providers.
• Experience in inpatient and/or outpatient care settings.
• Knowledge of DSM V or the most current diagnostic manual edition.
• Ability to analyze specific utilization issues and implement solutions that impact quality of care.

• Clinical Experience: Minimum of 2+ years in a clinical setting.
   
  Certifications: Must have one of the following:
• CEAP – Certified Employee Assistance Professional
• LCSW – Licensed Clinical Social Worker
• LMFT – Licensed Marriage and Family Therapist
• LMSW – Licensed Master Social Worker
• LPC – Licensed Professional Counselor
• RN – Registered Nurse
• State and/or Compact State Licensure required

• Education: Dependent on certification held:
• Associate's degree in Nursing
• Bachelor's degree in Social Work
• Master's degree in Social Work (Required for certain roles)