Insurance Implementation Specialist Jobs in Michigan

Under the supervision of the Director of Adult Initiatives, the Clinical Specialist is responsible for providing monitoring and oversight of clinical services delivered by the Detroit Wayne Integrated Health Network (DWIHN) network of contracted providers. The Clinical Specialist will ensure that the implementation of physical and behavioral health services is delivered in line with DWIHN and MDHHS contractual obligations. The Clinical Specialist will function as part of a multi-disciplinary team to ensure beneficiaries receive the appropriate service provisions based on the clinically appropriate level of care. The Clinical Specialist will be responsible for oversight of the adult I/DD provider network. This person will be dedicated to ensure that clinical practices and outcomes are being monitored and that DWIHN is incompliance with the MDHHS HAB Waiver clinical audit.

NOTE: (This position works in the Clinical and Practice Improvement Department)

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Provides clinical oversight of the contract with the Clinically Responsible Service Providers (CRSP) and clinical oversight on the implementation of physical and behavioral health integration across the Detroit Wayne Integrated Health Network (DWIHN) provider network.
• Develops policies and procedures in accordance with MDHHS and DWIHN protocols which facilitates appropriate service delivery and coordination of care between the CRSP and Integrated Care Organizations to persons served across all disability designations.
• Provides clinical and fiscal oversight of the contract with DWIHN providers by reviewing monthly itemized and detailed budget summary reports to approve all appropriate expenditures.
• Develops, provides oversight and analyzes clinical reports to determine utilization patterns and trends for individuals receiving services.
• Provides education and training to the Network and its contractors on policies and procedures included in this role.
• Identifies and supports evidence-based practice and or best practices implementation across the provider network and ensures fidelity standards are met.
• Works closely with the DWIHN Access and Call Center to review eligibility criteria for services and disability designations and to facilitate referral and coordination with the CRSP.
• Works in collaboration with the DWIHN Quality Department on policy and procedure necessary for network adequacy.
• Works in collaboration with the DWIHN Quality department to develop Performance Improvement Plans (PIP) for audits and accreditation (HSAG, NCQA).
• Works in collaboration with the DWIHN-Integrated Health team regarding physical health integration initiatives impacting the DWIHN provider network.
• Works in collaboration with the Customer Services department and provider network to resolve member related satisfaction issues.
• Works with Recipient Rights on grievances, appeals and denial related issues when needed.
• Conducts regular meetings and community forums for stakeholders and persons served to provide education, training, and updated information regarding policies and procedures specific to the contracted provider network.
• Works collaboratively with the Adult Initiatives Director to address satisfaction of persons served with regard to service delivery.
• Ensures data submitted by the CRSP follows the Health Insurance Portability and Accountability Act (HIPAA).
• Provides technical assistance and monitoring to the CRSP specific to access and coordination of services.
• Coordinates monthly meetings with CRSP to ensure appropriate utilization and reporting of services.
• Develops and analyzes clinical reports for persons served to determine patterns and trends and to develop plans of action for providers who do not meet required standards.
• Serves as part of a multi-disciplinary team to ensure beneficiaries receive the appropriate service provisions based on the clinically appropriate level of care.
• Provides oversight of the adult I/DD provider network.
• Ensures that clinical practices and outcomes are being monitored and that DWIHN is in compliance with the MDHHS HAB Waiver clinical audit.
• Performs related duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES (KSA’S)

• Knowledge of DWIHN policies, procedures and practices.
• Knowledge of the DWIHN provider network and community resources.
• Knowledge of the Michigan Mental Health Code.
• Knowledge of MDHHS policies, rules, regulations and procedures.
• Knowledge of medical and behavioral health practices and terminology.
• Knowledge of compliance standards.
• Knowledge of documents / regulations that govern the provision of mental health services, e.g., Medicaid Manual Mental Health and Substance Abuse Chapter III, State Plan for Medicaid, Michigan Department of Health and Human Services Quality Plan, BBA requirements and the Mental Health Code.
• Knowledge of the practices and principles of psychological, emotional, and sociological assessment and diagnosis.
• Knowledge of regulatory and industry best practice standards.
• Knowledge of Community Mental Health Services Programs (CMHSP) and Prepaid Inpatient Health Plans (PIHP).
• Knowledge of Integrated Care practices and principles.
• Knowledge of and ability to use multiple technology systems.
• Knowledge of HAB Waiver and HAB Waiver requirements.
• Knowledge of the adult I/DD provider network.
• Knowledge of the continuum of care for all disability designations (I/DD SED, SMI, Co-Occurring Disorder).
• Computer skills
• Time management skills
• Organizational skills
• Critical thinking skills
• Teamwork skills.
• Conflict Resolution skills
• Problem-Solving skills
• Decision Making skills
• Negotiation skills
• Project Management skills
• Assessment skills
• Report writing skills
• Communication skills
• Multitasking skills
• Analytical skills
• Adaptability skills
• Interpersonal skills
• Teamwork skills
• Ability to communicate orally.
• Ability to communicate in writing.
• Ability to work effectively with others.
• Ability to work with an ethnically, linguistically, culturally, economically and socially diverse population.
• Judgement/Reasoning ability

REQUIRED EDUCATION:

A Master’s Degree in Social Work, Psychology, Counseling, Nursing (a Bachelor’s Degree with a RN license will be accepted), the Human Services, the Social Services or a related field.

REQUIRED EXPERIENCE:

Three (3) years of professional clinical experience in public mental health.

Experience must include:

Experience providing services to children and adults with severe emotional disturbance, children and adults with intellectual and or developmental disabilities, adults with mental illness and/or individuals with substance use disorders.

REQUIRED LICENSE(S).

A Valid State of Michigan clinical licensure: RN, LMSW , LMHC, LPC, LLP or PhD.

A Valid State of Michigan Driver’s License with a safe and acceptable driving record.

WORKING CONDITIONS

Work is usually performed in an office setting but requires the employee to drive to different sites throughout Wayne County and the State of Michigan. This position can work remotely with supervisory approval.

This description is not intended to be a complete statement of job content, rather to act as the essential functions performed. Management retains the discretion to add or change the position at any time.

Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process.

The Detroit Wayne Integrated Health Network is an Equal Opportunity Employer