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Utilization Management Specialist (RN)

- Fulltime  

Job description

This unit manages the prior authorization and other utilization management functions. This position is responsible for providing clinical review of person-centered plans and request for services to ensure members receive services in the least restrictive, most clinically appropriate setting consistent with clinical standards of care. The position is responsible for providing technical assistance to the provider network and assisting in identification of the most clinically appropriate treatment options for members.


Essential Functions

The UM Specialist is responsible for (though not limited to):


  • Performs utilization management to ensure continuity of care and that members receive the right service, at the right time, at the right frequency.
  • Performs prior authorization review, continued stay and discharge reviews for behavioral health services. Staff will use clinical criteria by interacting with providers and collecting key information and narrative information regarding members seeking services or appropriate levels of care.
  • Conducts chart reviews of instances of care authorized for utilization purposes, case reviews for individuals that are identified as either over or under-utilizers of services.
  • Provides linkage, authorizations and level of care determinations to core services agencies and other providers, assisting providers with creative problem solving to suggest alternative approaches to care.
  • Utilizes clinical knowledge of a range of behavioral health diagnoses for children and adults and the psychosocial issues members face, such as eating disorders or homelessness. Utilizes knowledge of clinical skills, and techniques, such as reframing, diagnostic assessment, and evidenced based practices. Makes sound judgments based on clinical and legal requirements, member’s needs, including health and safety risks and available services and community resources.
  • Performs incoming and outgoing calls as appropriate in accordance with procedures.
  • Provides customer support and information to providers. Facilitates resolution of complaints and ensures linkage to accountable individuals in cases where additional response is needed.
  • Documents accurately and comprehensively all contacts and other correspondence with other staff and providers.
  • Processes requests within required timelines and meets established productivity standards.
  • Utilizes established protocols for review of treatment authorization requests, including applying Cardinal Innovations authorization guidelines, and documentation requirements.
  • Utilizes established systems to verify member eligibility, treatment history, and pharmacy data as needed for authorization reviews.
  • Attends internal and external meetings and training as needed to stay informed of changes in local, State, Federal and Division requirements.
  • Continues to increase knowledge of changes in clinical best practices.
  • Identifies reasons for re-admits/system failures as well as barriers to receiving services (e.g., transportation, need for further clinical assessment, identification of available resources, referrals)
  • Supports hospital and community stakeholders to assist with member transitions back to community setting and reduce readmissions
  • Participates in clinical rounds/ supervisor consultations as indicated and provides follow up to action steps
  • Participates in multidisciplinary case conferences to provide direction and clinical recommendations to staff managing complex and high-risk cases providing subject matter expertise
  • Collaborates with other departments in determining methods for improving comprehensive member care (including physical, emotional, social, and economic factors) to improve outcomes for members


Knowledge, Skills and Abilities:  


  • A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance from the Supervisor. This will require exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts. Problem solving, negotiation, arbitration and conflict resolution skills are essential to balance the needs of both internal and external customers.
  • Knowledge of prior authorization review continued stay and discharge reviews for behavioral health services to ensure appropriate amount and level of care for members.
  • Knowledge of documentation and clinical protocols for utilization purposes and case reviews for individual members in order to conduct chart reviews.
  • Knowledge of providing linkage, authorizations and level of care determinations to providers, assisting providers with creative problem solving to suggest alternative approaches to care.
  • Clinical knowledge of managed systems of behavioral health to also include co-occurring disorders. Knowledge of managed behavioral care practices and principles in order to provide services
  • Knowledge of relationship development and collaboration with other services, providers and other agencies that also affect access and services within the system.
  • Clinical knowledge of diagnosis and clinical practice standards for treatment as a basis for clinical reviews and decisions for authorization.
  • Knowledge of care management systems and documentation practices.
  • Clinical ability to recognize gaps in Cardinal Innovations service network and ability to communicate these identified gapes to appropriate parties.
  • Comprehensive knowledge of resources and the ability to use a personal workstation. Knowledge of databases and data entry is essential.
  • Mastery of care management to perform work as an UM Specialist to ensure continuity of care and clinically appropriate services are received.

•      Registered Nurses in this role should also have familiarity with behavioral health medications and be able to provide subject matter expertise related to physical health conditions and best practices.



To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


Education and Work Experience


·       A Master’s degree in a Human Services field (such as Psychology, Social Work, etc.) is required, along with at least two years of post-degree progressive experience providing similar services to the population served. 


·       The position requires a valid North Carolina full licensure from a behavioral health licensure board such as a LCSW, LPA, LMFT, LCAS, LCMHC. Or Licensed to practice as a Registered Nurse in the State of North Carolina, with minimum, of three years’ experience in the specialization area of Behavioral health.