Utilization Management Specialist

Working onsite at our Cambridge City, IN location

We offer competitive salary, full benefits package, Paid Time Off, and opportunities for professional growth.

Pinnacle Treatment Centers is a growing leader in addiction treatment services. We provide care across the nation touching the lives of more than 30,000 patients daily.

Our mission is to remove all barriers to recovery and transform individuals, families, and communities with treatment that works.

Our employees believe we are creating a better world where lives and communities are made whole again through comprehensive treatment.

As a Utilization Management Specialist II, you are required to work independently to determine the clinical severity of an illness and the intensity of the service criteria for a patient receiving care within our network. You will need to exhibit excellent communication and documentation skills and work closely with insurers, accrediting bodies, and other healthcare providers.

Requirements:

• Master’s Degree in Social Work, Psychology, Counseling, or related Human Services field is required.
• Licensed Clinical Social Worker (LCSW), Licensed Psychologist (LP), Licensed Professional Counselor (LPC), or Registered Nurse is required. Licensed Clinical Drug and Alcohol Counselor (LCADC) is preferred.
• Minimum of five years’ experience in the mental health and substance abuse field required; experience with all target populations and direct experience performing benefits and/or utilization management in a managed care setting preferred.
• Understand current DSM (Diagnostic and Statistical Manual) and ASAM (American Society of Addiction Medicine) Medical Necessity Criteria and demonstrate competence in making mental health and chemical dependency provisional diagnoses and level of care recommendations with available information.
• Knowledge and background with managed care and insurance preferred.
• COVID –19 Vaccination / approved exemption status

Responsibilities:

• Maintain high level knowledge of behavioral health utilization review criteria and best practices including coordination of care with insurance companies, Medicaid, and other payor sources.
• Familiarity with current provider manuals by insurer.
• Review with behavioral health companies updated clinical information on a timely basis for the purpose of utilization management certification, continued stay, and transition of care.
• Provide telephonic intake and crisis triage, verification of benefits, provide accurate documentation, scheduling and level of care determination using medical necessity guidelines.
• Oversee daily UR process at designated Recovery Works/Pinnacle location(s) and take appropriate action when necessary. Close communication with the facility treatment teams and accountability to inform leadership of any issues pertaining to complete, accurate, timely documentation.
• Document all certification information received and advise Administration Department of any insurance problems.
• Effectively input all authorization daily into the agency’s billing software/database for applicable Recovery Works/Pinnacle location(s).
• Process appeals with managed care companies. Ensure documentation submitted is complete, accurate, and timely.
• Participate in multidisciplinary team and Flash meetings for current clinical status and to maintain consistency in documented issues in the Electronic Medical Record.
• Review hard copy authorizations for potential problems and notify appropriate Leadership.
• Assist in case management and transition of care duties as assigned.

Benefits:

• 18 days PTO (Paid Time Off)
• 401k with company match
• Company sponsored ongoing training and certification opportunities.
• Full comprehensive benefits package including medical, dental, vision, short term disability, long term disability and accident insurance.
• Substance Use Disorder Treatment and Recovery Loan Repayment Program (STAR LRP)

Join our team. Join our mission.

IND2

Experience

• 5 year(s): Experience in the mental health and substance abuse field required

Education

• Bachelors or better

• Masters or better

Licenses & Certifications

• Lic Clinical Social Wrkr
• Lic Cert Alc & Drug Coun
• Registered Nurse
• Lic Prof Clin Counselor
• Licensed Psychologist

Behaviors

• Functional Expert: Considered a thought leader on a subject
• Team Player: Works well as a member of a group
• Dedicated: Devoted to a task or purpose with loyalty or integrity

Motivations

• Self-Starter: Inspired to perform without outside help
• Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization

Pinnacle Treatment Centers is an equal employment opportunity employer and makes employment decisions based on merit and other legitimate business considerations. We want to have the best available persons in every job. Company policy prohibits unlawful discrimination based on race, traits historically associated with race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), parental leave, national origin, gender, gender identity, gender expression, age, ancestry, physical or mental disability, military and veteran status, marital status, sexual orientation, genetic characteristics or information, political affiliation, non-merit based factors or any other consideration made unlawful by applicable federal, state, or local laws. It also prohibits discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has or is perceived as having any of those characteristics.