Utilization Management Support Specialist (Management Analyst I)
Monitors, drafts and submits service authorization requests to CSB contracted managed care organizations in a timely manner. Collaborates with supervisor and clinical teams to proactively address barriers to the timely submission of service authorization requests or to obtaining approvals for the requests. Reviews the CSB's EHR to identify new services that require a service authorization; monitor services with expired or soon-to-expire authorizations. Collaborates with the clinical team and provide guidance on determining the appropriate levels of care for CSB consumers. Performs concurrent and retrospective reviews of clinical documentation to ensure that documentation accurately reflects the services provided to the client and the outcomes communicated to Medicaid Managed Care Organizations. Interfaces with Medicaid Managed Care Organizations to respond to questions about patient care outcomes and the medical documentation required to obtain service authorization approval. Manages service authorizations in the EHR and track payment denials due to service authorization errors. Resolves any discrepancies by working with the managed care organizations (MCOs) and/or clinical staff. Provides support and assistance to the Utilization Manager in developing and conducting trainings and orientations on service authorizations and medical necessity documentation. Assists with the development of reports and analyses that measure and effectively communicate the CSB's utilization management efforts. Participates in internal and external committees and workgroups that inform CSB service authorization and clinical documentation best practices. Remains abreast of the Managed Care Organizations' standards for service authorization submissions. Communicates the standards to the Utilization Manager to inform proactive adjustments to the CSB's regulations, procedures, and EHR configuration.
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Any combination of education, experience, and training equivalent to the following: graduation from an accredited four-year college or university with a bachelor's degree in a business administration, public administration, statistics or field related to the assigned functional area such as human resources, budgeting and financial management, or contract administration and business management.
BRIDGE CLASS EMPLOYMENT STANDARDS:Four years of increasingly complex technical experience in the assigned functional area, comparable to experience at the Admin Assistant IV, or higher, level.
This class can serve as a bridge class enabling individuals who do not meet the educational or professional experience standards listed above to qualify for this class by possessing four years of increasingly complex technical experience in the assigned functional area, comparable to experience at the Admin Assistant IV, or higher, level.
The purpose of this bridge class is to promote upward mobility within the Fairfax County workforce. However, persons qualifying for this class on the basis of their technical experience may not substitute this technical experience for education, or for professional experience, in order to qualify for other employment opportunities.
CERTIFICATES AND LICENSES REQUIRED:
Bachelor's degree in human services or other related field required and at least one year of demonstrated work experience with direct client contact. experience with clients who have substance abuse and mental health issues. experience submitting service authorizations
NECESSARY SPECIAL REQUIREMENTS:
The appointee to this position will be required to complete a criminal background check, a Child Protective Services Registry, and a check with the Office of the Inspector General (OIG) to the satisfaction of the employer.
Requires travel to various CSB agencies to attend essential meetings and trainings. All duties performed with or without reasonable accommodations.
Panel interview; may include a written sample exercise.
It is the policy of Fairfax County Government to prohibit discrimination on the basis of race, sex, color, national origin, religion, age, veteran status, political affiliation, genetics, or disability in the recruitment, selection, and hiring of its workforce.
Reasonable accommodations are available to persons with disabilities during application and/or interview processes per the Americans with Disabilities Act. Contact 703-324-4900 for assistance. TTY 711. EEO/AA/TTY.