PRINCIPAL RESPONSIBILITIES:
Under the supervision of theSenior Director of Behavioral Health this position works directly with the BH department and staff, members, case management, and providers in assessing and providing appropriate services to achieve positive health outcomes. This position is responsible for reviewing and processing requests for authorization and notification of psychological testing and psychiatric services from health professionals, clinical facilities, and behavioral health providers. This position will be responsible for prior authorization and referral processes and directly interact with provider, facilities, and members. The BH Triage Specialist is responsible for the Utilization Management of members who require and request Behavioral Health services. This position will conduct clinical reviews of outpatient authorization requests.
Principal responsibilities include:
Maintains clinical expertise and knowledge of best practices for all relevant clinical areas of behavioral health including statutory and regulatory requirements.Work closely with licensed and unlicensed staff to co-manage the care of complex cases telephonically through regular contact with members, caretakers, healthcare professionals and others involved in the members care.Review screening tools, assessments, and other documentation to triage members referrals from health professionals, clinical facilities, and ancillary providers for mental health services and possible case management.Be readily available via phone queue for possible crisis/emergent calls via the member services call center.Provide risk assessments for members who meet criteria based upon Medi-Cal screening tool responses and identify/coordinate referral options in a timely manner.Reviews activities including progress and barriers towards goals, resolves conflicts or strategizes solutions to support coordination of services/care as needed.In conjunction with compliance, reviews and analyzes reports and policies provided by delegated vendors and participates in on-site audits as requested.Adheres to administration of behavioral health care services including identification and development of clinical practice guidelines and associated trainings.Participates in clinical discussions with providers and community agencies to encourage the incorporation of behavioral health care aspects into their services and planning efforts.Collaborates with the other local agencies focused on special needs, mental health and substance use, including Regional Center, Alameda County Behavioral Health (ACBH), and Drug Medi-Cal Organized Delivery System to ensure smooth transitions across the continuum of health care.Provide timely clinical review of Behavioral Health authorization requests using clinical policies and procedures and nationally recognized evidence-based clinical review guidelines.Gathers pertinent medical information, screens prior authorization requests for the Senior BH Director.Reviews ICD-10, CPT-4 and HCPCS codes for accuracy and existence of coverage.Refers cases of possible over/under utilization to the Senior BH Director.Meets productivity and quality of work standards on an ongoing basis. Assess members health care status, history, risks, and utilization.Identify members for potential case management and potential quality issues and refer appropriately.Assist case management staff with coordinating care for members who have difficulty/barriers accessing care.Provide clinical support and guidance to non-clinical staff.Communicate, as needed, with the Senior BH Director and the Senior Medical Director to validate patient acuity and plan of care; refer authorization requests for potential denial to the Senior BH Director.Complete other duties and special projects as assigned.
ESSENTIAL FUNCTIONS OF THE JOB
Maintains clinical expertise and knowledge of best practices for all relevant clinical areas of behavioral health including statutory and regulatory requirements.Work closely with licensed and unlicensed staff to co-manage the care of complex cases telephonically through regular contact with members, caretakers, healthcare professionals and others involved in the members care.Review screening tools, assessments, and other documentation to triage members referrals from health professionals, clinical facilities, and ancillary providers for mental health services and possible case management.Be readily available via phone queue for possible crisis/emergent calls via the member services call center.Provide risk assessments for members who meet criteria based upon Medi-Cal screening tool responses and identify/coordinate referral options in a timely manner.Reviews activities including progress and barriers towards goals, resolves conflicts or strategizes solutions to support coordination of services/care as needed.In conjunction with compliance, reviews and analyzes reports and policies provided by delegated vendors and participates in on-site audits as requested.Adheres to administration of behavioral health care services including identification and development of clinical practice guidelines and associated trainings.Participates in clinical discussions with providers and community agencies to encourage the incorporation of behavioral health care aspects into their services and planning efforts.Collaborates with the other local agencies focused on special needs, mental health and substance use, including Regional Center, Alameda County Behavioral Health (ACBH), and Drug Medi-Cal Organized Delivery System to ensure smooth transitions across the continuum of health care.Provide timely clinical review of Behavioral Health authorization requests using clinical policies and procedures and nationally recognized evidence-based clinical review guidelines.Gathers pertinent medical information, screens prior authorization requests for the Senior BH Director.Reviews ICD-10, CPT-4 and HCPCS codes for accuracy and existence of coverage.Refers cases of possible over/under utilization to the Senior BH Director.Meets productivity and quality of work standards on an ongoing basis. Assess members health care status, history, risks, and utilization.Identify members for potential case management and potential quality issues and refer appropriately.Assist case management staff with coordinating care for members who have difficulty/barriers accessing care.Provide clinical support and guidance to non-clinical staff.Communicate, as needed, with the Senior BH Director and the Senior Medical Director to validate patient acuity and plan of care; refer authorization requests for potential denial to the Senior BH Director.Complete other duties and special projects as assigned.
ESSENTIAL FUNCTIONS OF THE JOB
Serve as subject matter expert in BHT/ABA and behavioral health and clinical programs in support of the Triple Aim of improving patient experience of care, health outcomes, and reducing overall cost.Timely review of outpatient authorization requests within regulatory guidelinesCommunicate and coordinate with Behavioral Health providers, specialists and vendors as appropriate to determine medical necessity of a request.Serve as a clinical resource to other clinical staff and non-clinical staff, as neededCommunicate effectively, both verbally and in writingAbility to multi-task and prioritize tasks.Work closely and in collaboration with all staff to maintain open communication among all the clinical departments and create a positive team culture.Perform all job functions with integrity and provide timely internal and external customer service in cooperative, professional, and respectful manner.Comply with the organizations Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.Maintain active unrestrictive license(s) required for position.
PHYSICAL REQUIREMENTS
Constant and close visual work at desk or computer.Constant sitting and working at desk.Constant data entry using keyboard and/or mouse.Frequent use of telephone headset.Constant verbal and written communication with staff and other business associatesFrequent lifting of folders and other objects weighing between 0 and 30 lbs.Frequent walking and standing.
Number of Employees Supervised:0
MINIMUM QUALIFICATIONS:
EDUCATION OR TRAINING EQUIVALENT TO:
Active and unrestricted California License as an:
Psychologist, LCSW (Licensed Clinical Social Worker), LMFT (Licensed Marriage Family Therapist), or RN (Registered Nurse)

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
Three years clinical experience in an acute or residential setting preferred
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
Two years of Managed care experience preferred (HMO or IPA)Knowledge of Medi-Cal regulations preferredExperience with BH related evidenced based criteria (Milliman, InterQual) preferredExperience in a medical/public health setting preferred.Ability to communicate well with members, providers, and team members.Ability to prioritize case load.Excellent verbal and written communications skills.Working knowledge of CPT, ICD-10, and HPCS codingExperience in use of various computer system software as well as Windows and current Microsoft Office suite
SALARY RANGE: $105,853.04 - $158,779.55 ANNUALLY
The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.