Manager Aetna Utilization Review Jobs (NOW HIRING)

Position Function: Responsible for ensuring that youth receive the most appropriate level of residential services for well-being and to achieve permanency. Responsible for ensuring that exceptional services and/or placement waivers are secured and reviewed, with all deadlines met. Negotiate and communicate with parties within and outside of OCOK. Responsible for tracking length of stay and initiating measures for ensuring stepping down youth to achieve timely permanency. 

Educational Requirements: A bachelor’s degree from an accredited college or university is required; a master’s degree in social work or related field is preferred. 

Experience Requirements: A minimum of three years of experience working with children, youth and families in foster care or related experience with some knowledge of the regulations that guide residential services is required. Experience working with children and youth through the adoption process. Experience with utilization management in behavioral and/or medical healthcare. Experience driving quality and timely discharge planning from residential facilities as deemed appropriate in review of child’s assessments and progress. 

Functional Requirements: Must have excellent verbal and written communication skills and the ability to work collaboratively with youth, families, collaborating agencies, community professionals, and OCOK/ACH Child and Family Services staff. Must be willing to increase knowledge in the application of all related standards that govern residential services. Must demonstrate excellent organizational skills as well as the ability to develop systems that support compliance. Must work autonomously to ensure that all deadlines are met, and utilization review tasks are completed. Must demonstrate an ability to continue learning through supervision, continuing education, and experience, and work cooperatively using a team approach. Must be willing to put into practice Trauma-Informed Care principles. 

Working Conditions: Position includes exposure to parents, guardians, and conservators as well as to youth with behavioral problems, including possible physical aggression. Will be required to travel to attend meetings, training, or conduct business off site. Must have a valid driver's license and meet agency’s underwriting standards if driving on agency business. A personal vehicle is required for travel. 

Exposure to Confidential Information: The Utilization Review Specialist will have access to confidential records including youth files, foster care/adoption records, foster/adopt parent information and biological family history. Must maintain confidentiality and follow policies related to personnel records and client records.

Key Expectations/Responsibilities:

Planning

• Coordinates and/or participates in meetings with collaborating partners and agencies as assigned.
• Participates in other administrative and planning meetings as needed to facilitate referral and placement.
• Initiates and facilitates step-down and other utilization related meetings. 
• Coordinates and manages all utilization review tasks for OCOK related to placement with or between Network Provider. 

Implementation

• Receives and reviews client information from OCOK, DFPS, Network Providers, and other agencies to ensure the appropriate utilization of services to youth placed in an OCOK Network Provider. 
• Reviews and responds to all 3rd party level of care utilization reviews to ensure that OCOK youth are receiving appropriate services based on their needs. Will track Network Provider progress. 
• Responsible for ensuring that exceptional services are negotiated, secured, reviewed, approved, and implemented, with all deadlines met. 
• Ensures services adhere to applicable OCOK policy and procedures and other Contract outcomes.
• Maintains an up-to-date listing of all Agency network providers and services.
• Ensures youth are placed in properly trained and licensed facilities with appropriate capacity to provide services.
• May participate in crisis calls as they relate to provision of services. 
• Requests documentation to ensure psychological and/or psychiatric services are provided as needed when performing utilization reviews. 
• Tracks length of stay for youth placed with OCOK and ensure that youth are stepping down and achieving permanency. 
• Complete Utilization Review for clients in residential facilities as necessary. 
• Reviews documentation provided for youth’s Service Planning as needed to review utilization. 
• Reviews child assessment tools as needed to ensure proper utilization of services.          
• Ensure quantified and measurable data is used during the child assessment phase to make appropriate decisions regarding the type and level of placement for the child and for the purpose of identifying needed family services.     
• Ensures youth placed in higher level settings are properly placed and stepped down to a less restrictive setting in accordance with treatment goals and length of stay compliance.                                         
• Promotes safety and encourages the least-restrictive and shortest length of out-of-home placement for children.
• Reviews provider documentation and conducts on-site inspections to determine that services outlined in rate agreements are being implemented.
• Ensures contract outcome measures are met with emphasis on utilization management. 
• Refrains from assuming any duty that is unrelated to and/or interferes with the responsibilities of the position.
• Advocates, promotes, and practices cultural sensitivity and responsiveness in all day-to-day interactions.
• Develops, promotes, and practices teamwork in all activities.
• Completes other duties as assigned.

Training

• Attends relevant in-service training offered at ACH to expand knowledge of services and the application of clinical skills.
• Attends mandatory training such as, but not limited to, Emergency Behavior Intervention, CPR and First Aid, Psychotropic Medications and Trauma-Informed Care training.
• Communicates regularly with Therapeutic Services Manager and seek supervision when appropriate.
• Attends continuing education necessary to expand knowledge and maintain certifications or licenses.
• Notifies supervisor properly when absent.
• Ensures that all deadlines are met and decisions affecting OCOK payments are communicated. 
• Establishes effective working relationships with co-workers.
• Deals satisfactorily with and acknowledges work-related stress.
• Maintains appropriate boundaries between professional and personal issues.
• Adheres to all policies and procedures of the agency and its accrediting and standard setting bodies, such as Council on Accreditation (COA) and state licensing.
• Respects the dignity and worth of all clients and families.
• Maintains client confidentiality per agency standards and all applicable codes of ethics.
• Uses outside professional collaboration and intra-agency teamwork appropriate to the agency.
• Learns, understands, and supports the agency’s mission, purpose, and function.
• Is prepared to address appropriate issues during supervisory conferences and meetings.
• Accepts direction from supervisor and implements supervisor’s suggestions and instructions.
• Understands the job description in relation to other agency positions.
• Continues to work to improve skills needed for position held.
• Considers the environmental, cultural, safety, diversity issues and needs of the clients.
• Identifies and understands the strengths, abilities, and competencies of the clients.

The above-mentioned job description is not intended to describe, in detail, the multitude of tasks that may be assigned but rather to give the employee a general sense of the responsibilities and expectations of his/her position. As the nature of business demands change so, too, may the essential functions of this position.

Position Function: Responsible for ensuring that youth receive the most appropriate level of residential services for well-being and to achieve permanency. Responsible for ensuring that exceptional services and/or placement waivers are secured and reviewed, with all deadlines met. Negotiate and communicate with parties within and outside of OCOK. Responsible for tracking length of stay and initiating measures for ensuring stepping down youth to achieve timely permanency. 

Educational Requirements: A bachelor’s degree from an accredited college or university is required; a master’s degree in social work or related field is preferred. 

Experience Requirements: A minimum of three years of experience working with children, youth and families in foster care or related experience with some knowledge of the regulations that guide residential services is required. Experience working with children and youth through the adoption process. Experience with utilization management in behavioral and/or medical healthcare. Experience driving quality and timely discharge planning from residential facilities as deemed appropriate in review of child’s assessments and progress.