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Location: This position is located at our Dublin, OH campus with hybrid flexibility (3 days home/2 days in office)

Who we are  

Founded in 1999 and headquartered in Central Ohio, we’re a privately-owned, independent healthcare navigation organization. We believe that no one should have to navigate the cost and complexity of healthcare alone, and we’re on a mission to make healthcare simpler and more effective for our millions of members. Our big-hearted, tech-savvy team fights to ensure that our members get the care they need, when they need it, at the most affordable cost – that’s why we call ourselves Healthcare Warriors®.   

We’re committed to building diverse and inclusive teams – more than 2,000 of us and counting – so if you’re excited about this position, we encourage you to apply – even if your experience doesn’t match every requirement. 

About the role  

The Behavioral Health Utilization Management Clinician provides utilization management for all behavioral health and substance use disorder levels of care as indicated per the Health Benefit Plan. The clinician is responsible for processing all clinical documentation and appropriately reviewing the services requested against plan language and appropriate criteria; within the designated time frames indicated. The Behavioral Health Utilization Management Clinician also partners with providers and facilities to assist with discharge planning. The Behavioral Health Utilization Management Clinician provides the highest level of customer service both internally and externally to promote quality, medically necessary, cost effective care.

What you’ll do  

• Assess and review all requests for all behavioral health and substance use disorder inpatient and outpatient levels of care and transitions in relation requiring clinical review against plan language and the appropriate clinical criteria. Conduct initial clinical review, concurrent review, and retrospective review.
• Utilize critical thinking and clinical knowledge to make independent decisions and determinations, following Quantum Health workflows.
• Utilize Quantum Health adopted clinical criteria during all aspects of the review process and document outcomes in authorization database.
• Facilitate discharge planning process during concurrent review and post discharge. This includes making arrangements for Residential, PHP, IOP and other outpatient services.
• Communicate with patient, provider, facility, and internal work groups regarding outcome of requests. Promote the mission and core values of Quantum Health.
• Research status of vague or questionable procedures and present to the Chief Medical Officer/Physician Peer Reviewer for review. Notify Chief Medical Officer/Physician Peer Reviewer of all potential non-certifications within the appropriate time frames.
• Prepare and present high-quality medical reviews for MD collaboration and determination.
• Facilitate communication between medical provider including external review agencies.
• Negotiate for services needed if no clear benefit exists or if the services can only be provided out of network.
• Coordinate health management services in an effort to provide integrated health services for each patient and provide benefit and health information to patients, caregivers, providers and facilities so they are able to make informed health decisions.
• Re-direction of out of network service requests to in network whenever possible to ensure members obtain the optimum benefit.
• Identify potential cases for high risk/high cost and refer to the appropriate case management team. Maintain contact with internal clinical staff for transfer of cases for medical management when appropriate.
• Maintain a working knowledge of all Quantum Health workflows.
• Be a clinical resource for all Quantum Health work groups. 
• Provide monitoring and oversight of non-clinical staff activities and be available to non-clinical staff during Quantum Health’s business hours.
• Other duties as assigned

What you’ll bring

• Licensure/Certifications: Registered nurse with active license in Ohio or Licensed Social Worker with current and active license in Ohio
• Minimum of 4 years’ experience in a Behavioral Health setting
• Experience in health management preferred
• Ability to make decisions that are timely and that achieve results consistent with business goals and organizational culture
• Driven to work independently with limited need for daily supervision
• Possess excellent verbal and written communication skills
• Strong ability to communicate effectively with patients, physician practices, hospital facilities
• Aptitude to research and identify issues using critical thinking
• Perform as a team member with the working group, interact professionally with other entities both internally and externally
• Proactively present issues and ask questions
• Outstanding computer skills, navigating multiple systems, and Microsoft applications
• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment
• Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently. 
• A high degree of personal accountability and trustworthiness, a commitment to working within Quantum Health’s policies, values and ethics, and to protecting the sensitive data entrusted to us. 

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