Prior Authorization Coordinator Jobs in Rockingham, NC

Position Qualifies for Hiring Bonus if Benefit Eligible

Company Mission Statement:

Our mission is to inspire and empower people to seek and maintain recovery and health. Daymark Recovery Services, Inc. is a mission driven, comprehensive community provider of culturally sensitive mental health and substance abuse services.

Comprehensive Benefits Package:

• Medical, Dental and Vision Insurance
• Health Spending Account
• Company-Paid Life Insurance
• Short Term Disability
• 401(k)
• Paid Holidays
• Paid Vacation and Sick Leave
• Employee Assistant Program
• Referral Bonus Opportunities
• Extensive Internal Training Program

PayScale: $21.63-$23.07/hr.

Summary:

Under direct and indirect supervision, provides case management assessment, person centered planning and documentation, referral and linkage, and monitoring/follow-up.

Essential Duties and Responsibilities:

• Provides care management assessment/reassessment, development of care management plans, referring and linking to needed services, monitoring/follow up with client and referrals, provide education for health promotion. Ensure metrics for outcomes are met.
• Participates in interdisciplinary treatment planning, consultation activities and ensures all involved parties are aware of the plan of care.
• Provides crisis intervention consultation to all participants of TCM and involves crisis services when needed.
• All other duties as assigned by supervisor.

The responsibilities of the Care  Manager include, but are not limited to, the following:  

Care Management Assessment

• Documents the client’s service needs, strengths, resources, preferences, and goals to develop a Care Management Plan.
• Gathers information regarding all aspects of the recipient, including medical, physical, psychosocial, behavioral, financial, social, cultural, environmental, legal, and vocational/educational areas.
• Integrates all current assessments including the comprehensive clinical assessment and medical assessments, including assessments and information from the HIE/Tailored Plan and the primary care or specialty care physician.
• Includes early identification of conditions and needs for prevention and amelioration.
• Consults with other natural and paid supports such as family members, medical and behavioral health providers, and educators to form a complete assessment.
• Performs periodic reassessment to determine whether a recipient’s needs or preferences have changed.

Care Management Plan/Documentation

• Ensures that person centered information is gathered and that the consumer’s health and safety risks are assessed prior to the development of the care management plan
• Works in conjunction with the client, family, friends, and providers who have lengthy experience with the person.
• Performs periodic revision of a plan based on the information collected from the person, family, other personal supports, and comprehensive clinical assessments or reassessments.
• Assist the person to obtain the outcomes/skills/symptom reduction that they desire.
• Contact the primary care physician to obtain clinical information pertinent to establishing person centered goals.
• Facilitates provider choice process, maintaining objectivity and providing fact-finding assistance.
• Ensures that signed Authorization to Disclose Health Information forms are obtained and on file in the consumer’s medical record prior to releasing any information when needed (Substance Use Disorders).
• Ensures that all information released/disclosed is documented on the Accounting of Release and Disclosure form (this includes documenting any documents given to consumer/legal guardian).

Referral/Linkage

     Referral and linkage activities connect a recipient with medical, behavioral, social and other programs, services, and supports to address identified needs and achieve goals specified in the Care Management Plan. Referral and linkage activities include but are not limited to:

• Coordinating the delivery of services to reduce fragmentation of care and maximize mutually agreed upon outcomes.
• Facilitating access to and connecting recipients to services and supports identified in the Person Centered Plan.
• Making referrals to providers for needed services and scheduling appointments with the recipient.
• Assisting the recipient as he or she transitions through levels of care.
• Facilitating communication and collaboration among all service providers and the recipient.
• Assisting the recipient in establishing and maintaining a medical home where needed.
• Assisting the recipient in establishing OBGYN and prenatal care as necessary.

Natural Support / Services Not Funded Through the Tailored Plan

• Assists consumer/legally responsible person in considering and accessing natural community supports such as educational services, transportation, support from friends/family/church, etc.
• Ensures that the consumer gets the best possible treatment and care by carefully coordinating paid supports/services with other resources available in the community.

Monitoring/Follow-Up

Monitoring and follow up includes activities and contacts that are necessary to ensure that the

Care Management Plan is effectively implemented and adequately addresses the needs of the recipient. Monitoring activities may involve the recipient, his or her supports, providers, and others involved in care delivery. Monitoring activities helps determine whether:

• Services are being provided in accordance with the recipient’s Care Management Plan;
• Services in the Care Management Plan adequate and effective;
• There are changes in the needs or status of the recipient; and
• The recipient is making progress toward his or her goals.
• Documents monitoring and the actions taken/planned as a result of the monitoring in the consumer’s record.
• Ensures that the monitoring schedule for each consumer is sufficient to assure the health, safety and welfare of the consumer.
• Monitors for progress/lack of progress through observation, interview, and documentation review. 

Coordination

• Works closely with the consumer/legally responsible person, provider agencies, and others involved with the consumer’s care and treatment to avoid/resolve scheduling conflicts, duplication of effort, and other problems that hinder effective treatment.
• Assists consumer in obtaining entitlement services whenever possible.
• Monitors the consumer’s continued eligibility for Medicaid and/or NC Health Choice, as applicable, and provides needed assistance to the consumer/legally responsible person in order to ensure that coverage does not lapse.

Outcomes

• Be responsible for the BH quality metrics for your assigned members

Units Billed Minimum Requirement: 

Care manager contacts for members with behavioral health needs:

High Acuity: At least four care manager-to-member contacts per month, including at least one in-person contact with the member.

Moderate Acuity: At least three care manager-to-member contacts per month and at least one in-person contact with the member quarterly (includes care management comprehensive assessment if it was conducted in- person).

Low Acuity: At least two care manager-to-member contacts per month and at least two in-person contacts with the member per year, approximately six months apart (includes the care management comprehensive assessment if it was conducted in-person).

Education and/or Experience: 

A bachelor’s degree in a human service field with two years MH/SA/DD experience with the population served; or,a licensed RN with two years MH/SA/DD experience with the population served. 

TCM trainings will be required to complete as assigned.