Director Utilization Management Jobs in Raleigh, NC

The Care Manager II-Facility Based provides Transitional Care Management and Physical Health Consultation for members with physical and/or behavioral health needs in Acute Care facilities, State Operated Developmental Centers, and Justice System settings. For Care Manager II-Facility Based assigned to a facility, there will be active and onsite participation in discharge planning beginning with admission.  

Responsibilities & Duties-

Provide Care Team Support

• Support members transitioning from inpatient settings to the appropriate and least restrictive lower or lateral level of care
• Provide subject matter expertise, within scope, regarding member’s physical and/or behavioral health to support the development and delivery of a whole person approach to Care Management 
• Work collaboratively with other Alliance staff, behavioral health providers, primary care physicians, specialty care providers and other community partners and stakeholders to support members in their home communities and address barriers

Core Transitional Care Management Functions

• Conducts on site visit the member during their stay in an institution (e.g., acute, subacute and long–term stay facilities) 
• Conduct outreach to the member’s providers
• Obtain a copy of the discharge plan ensure discharge plan is made available to authorized community providers who will be serving the member post discharge
• Facilitate clinical handoffs to other Health Plans and Providers as applicable
• Refer and assist members in accessing needed social services and supports identified as part of the transitional care management process, including access to housing, behavioral health services, residential services and supports, medical and wellness services
• Assist the member in obtaining needed medications prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management and support medication adherence
• Develop a ninety (90) day post-discharge transition plan prior to discharge from residential or inpatient settings, in consultation with the member, facility staff and the member’s care team, that outlines how the member will maintain or access needed services and supports, transition to the new care setting, and integrate into their community
• Communicate and provide education to the member and the member’s caregivers and providers to promote understanding of the ninety (90) day post-discharge transition plan
• Assist with scheduling of transportation, in-home services, and follow-up outpatient visits with appropriate providers within a maximum of seven (7) Calendar Days post-discharge, unless required within a shorter timeframe
• Conduct In reach and transitions for Special Populations receiving care in Inpatient settings (PRTF, SNF’s) 

Monitoring/Coordination

• Appropriately escalate high risk/high visibility and/or complex barriers/needs members who may have difficulty transitioning out of the facility in a timely manner to supervisors. High risk can involve Health and Safety of a member, staff, or organizational risk 
• Review cases with clinical complexity with direct supervisor and follow escalation protocols to ensure timely engagement from members or our Medical Team and Provider Networks 
• Obtain information releases that will improve care management activities on behalf of the member
• Reports care quality concerns to Quality Management as needed 

Documentation

• Ensure all clinical documentation (e.g. goals, plans, progress notes, etc.) meet state, agency, and Medicaid requirements
• Follow administrative procedures and effectively manages caseload

Data

• Review, validate and interpret risk stratification data and population health groups and recommend changes or adjustments to care management approach as needed
• Utilize data to analyze needs of the members we serve, guide staff training development, identify resource needs and consistency of workflow implementation across disciplines

Travel

• Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc. may be required
• Travel to meet with members, providers, stakeholders, attend court hearings etc. is required

Minimum Requirements-

Education & Experience

Required:

Graduation from an accredited school of Nursing and three (3) years of full-time, post degree experience providing care management, case management, care coordination, discharge planning, or utilization management to members with Behavioral Health and Physical Health conditions in a behavioral health, medical, or managed care setting. Must have a valid, active RN license in North Carolina. 

Or

Master’s degree from an accredited college or university in Human Services or related field and at least two (2) years of full-time, post graduate degree experience providing care management, case management, care coordination, discharge planning, or utilization management to members with Behavioral Health and Physical Health conditions in a behavioral health, medical, or managed care setting. Must have a valid, active clinical license (LCSW, LMFT, LCAS, LCMHC, LPA) in North Carolina.

Knowledge, Skills, & Abilities-

• A demonstrated Knowledge of the assessment and treatment of mental health, substance abuse, intellectual and developmental disabilities, 
• Knowledge of legal, waiver, accreditation standards and program practices/requirements. 
• Knowledge of the Alliance Health service benefit plans and network providers. 
• Person Centered Thinking/planning
• The employee must be detail oriented, 
• Ability to independently organize multiple tasks, priorities, and to effectively manage an assigned caseload under pressure of deadlines.
• Exceptional interpersonal skills, highly effective communication ability, 
• Ability to make prompt independent decisions based upon relevant facts and established processes.
• Problem solving, negotiation and conflict resolution skills 
• Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) is required.

Salary Range 

$69,592-$88,729/Annually 

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.