Manager of UM & Call Center

Are you interested in improving the quality of life for the people in your community? Do you have a passion for ensuring that those with mental health and substance use disorders receive the services they need? Are you looking for a place to work that is committed to the development of staff and matching people to work they love? A place that values a diverse workforce that strives for excellence while maintaining a healthy work/life balance?

Then come join us!

*SWMBH provides a potential for hybrid, work from home options after initial, in-office training period*

Minimum starting salary: $77,051 (compensation offered is based on candidate experience and qualifications)

Position Description:

Position Title: Manager of Utilization Management (UM) & Call Center

Department: Utilization Management

Reports To: Director of Utilization Management

Southwest Michigan Behavioral Health (SWMBH) is a $200 million governmental entity managing multiple Michigan Department of Community Health benefits management contracts and business lines over an eight county region in Southwest Michigan.

SWMBH is seeking a Manager of Utilization Management & Call Center. This position provides ongoing supervision and leadership to Utilization Management and Call Center staff while performing utilization management and Call Center functions of the Prepaid Inpatient Health Plan (PIHP) benefits management system. Ensures the Call Center provides cost effective and quality member care and access through the appropriate utilization of resources. Acts as a resource to the Call Center staff, administrative staff and external provider network in all issues related to utilization management, call center access, and assistance with complex care coordination referrals. Ensures Call Center business process and regional policy compliance with federal and state regulations, accreditation standards, other regulatory obligations, internal standards and requirements. Facilitates orientation and educational training for SWMBH staff on utilization management for regulatory and business process standards.

DUTIES and RESPONSIBILITIES:

• Oversees the development and implementation of the day-to-day operations of SWMBH's Utilization Management (UM) and Call Center department and ensure all practices comply with SWMBH's policies and procedures, Federal, State, and local requirements. Ensures the Prepaid Inpatient Health Plan (PIHP) is following Federal and State regulations, mandates, and guidelines relative to workloads and workflows regarding utilization reviews, care coordination, and the call center phone queues
• Manages and supports the day-to-day operations of the Medicaid, Healthy Michigan Plan and SUD Community Grant in SWMBH's Utilization Management and Call Center department, including, training UM staff, making and documenting centrally managed service request determinations, and coordinating resources and case consultations.
• Collaborates with SWMBH's Integrated Care Team and community providers to assist, when necessary, for transitions needed with complex cases from acute and sub-acute levels of care back to community providers.
• Promotes the exploration of new role models and innovative practice to improve systems and service efficiencies and effectiveness specifically in the realm of assessment, screening, triage, care coordination, and level of care.
• Provides primary administrative and clinical leadership for the administration and management of SWMBH utilization management of managed care functions and the direct management of the SWMBH care management functions.
• Manages UM/Call Center electronic health record needs and coordinates development with IT and software vendor.
• Manages call center/phone operations including emergency transfer of phones, troubleshooting problems, development and updates and assures 100% call center coverage, including contract coordination for afterhours service vendor.
• Manages medical necessity criteria training and inter-rater reliability testing for all SWMBH Care Managers.
• Reviews and coordinates call center call monitoring and corrective action with Regional Utilization Management and takes appropriate immediate action to improve effectiveness and efficiency.
• Monitors and coordinates any UM/Call Center concerns and/or administrative issues with Contracts and Provider Network departments.
• Assures providers have business process instructions and can readily assist with member care transitions to meet the federal and state timeliness standards.
• Oversees and conducts consultation and review of the outlier data utilizing appropriate eligibility, medical necessity, covered services, and other established criteria.
• Develops action plans jointly with relevant providers to address the outliers, when required.
• Oversees the administrative and clinical aspects of the utilization management functions of Medicaid/HMP/Block Grant Substance Abuse Services, and Medicaid/HMP/General Fund Inpatient, Crisis Residential, Partial Hospitalization for applicable CMHSP's.
• Any additional duties, as assigned.

ESSENTIAL FUNCTIONS:

• Provides daily oversight of Southwest Michigan Behavioral Health (SWMBH) regional central care management functions, consults with other central care management staff, and engages in cross functional collaboration with other departments, providers and CMHSP's.
• Provides day-to-day leadership, training, and consultation to UM staff.
• Impacts the delivery of care at the system level through direct utilization management, feedback of performance data, training, and supported consultation.
• Functions as the Subject Matter Expert for SMWBH UM development, phone operations, report management and accreditation/contractual daily business process.
• Provides administrative and clinical expertise, oversight, and consultation to promote high quality clinical care, uniformity of benefit and member benefit.

QUALIFICATIONS:

• Licensed Master Social Work (LMSW), Counseling (LPC), Psychology (LLP) or Registered Nurse (RN) is required. Certification as an Addiction Counselor is preferred.
• Experience in the mental health and/or substance abuse field is required. Experience with all target populations and direct experience performing benefits and/or utilization management in a managed care setting is preferred.
• Strong oral and written communication skills, and excellent interpersonal skills; excellent critical thinking and organizational skills; demonstrates effective interpersonal skills and customer service practices for a diverse population, primarily using telephonic methods.
• Ability to manage multiple projects simultaneously and meet required deadlines.
• Ability to collaborate with others within a team environment and effectively work independently.
• Understand the Diagnostic Statistical Manual (DSM) V-TR and ASAM and demonstrate competence in making mental health and chemical dependency provisional diagnoses with available information.
• Understands mental health and substance use disorder acute and community-based treatment modalities based on an assessment and medical necessity criteria.
• Ability to establish effective working relationships rapidly by telephone to gather necessary information quickly and accurately under occasionally difficult circumstances.
• Ability to relate and discuss benefit, medical necessity, and clinical information with Provider Network.
• Demonstrates knowledge of Provider Network specialties and makes appropriate referrals based upon clinicians' participation in Provider panels.
• Technology literate and working knowledge of Microsoft Office 365 applications including, Word, Excel, Outlook, and PowerPoint.
• Life experiences with diverse racial, ethnic, and cultural backgrounds, including experience with behavioral health issues is preferred.
• Must be supportive of culturally competent recovery-based practices and person-centered planning as a shared decision-making process.
• Must support a trauma informed culture of safety to aid consumers in their recovery process.

Individuals of diverse racial, ethnic, and cultural backgrounds including those with lived experience with behavioral health issues along with bilingual candidates are encouraged to apply.

Please apply through the Southwest Michigan Behavioral Health website at www.swmbh.org by December 2, 2024. Emailed resumes will not be accepted.

Position includes a full benefit package, and salary is commensurate with experience.

SNAPSHOT

Job Title: Manager of Utilization Management & Call Center

Experience: 3 - 5 Years

Position Type: Exempt

Industry: Healthcare

Required Travel: Minimal

Manages Others: Yes

Keywords: Utilization Management, Behavioral Health, Substance Abuse Treatment, Leadership, Manager