Company Overview

Our client is the leading group in the provision of mental health services in Puerto Rico. Consistent with its vision of being a world-class organization, ensuring that its associates, employees, and suppliers meet the highest ethical standards and the best quality and service practices in the health industry, such as telemedicine and home services.

Job Summary

The Health Professional conducts utilization review, and/or telephonic customer care; problem resolution, follow-up, and further related services for patients and members. This key individual focuses on member engagement, education, and empowerment, establishing recommendations that manage chronic health conditions and are conducive to healthier lifestyles. Must be available while non-clinical staff performs initial screening.

Responsibilities

Provides telephonic and/or in-person health coaching and consultation for participants and members, while meeting company policies and procedures. Verifies and documents member eligibility for services. Investigate, review, and maintain data related to treatment, care, and/or related services and identify barriers that could affect or interfere with treatment effectiveness or adherence.
Performs triage and urgent clinical risk assessment, clinical expert consultation, short-term problem resolution, clinical emergency or urgent services coordination, referral, and/or follow-up for members seeking services, as needed.
Participates in organization determinations for either Inpatient or Partial Hospitalization cases including pre-certification and concurrent reviews, while discussing clinical/medical necessity concerns with an in-house Physician Advisor, as needed. Collaborates with other professionals to obtain better treatment results and overall care. Communicates and interacts via “live” encounters with providers to facilitate and coordinate the activities of the Utilization Management process.
Verifies and adjusts Census reports for all Inpatient/Partial Hospitalization facilities and conducts concurrent and retrospective reviews while meeting company policies and procedures. Collaborates with facilities in Discharge planning. Completes Discharge summary using the clinical information provided by facilities at case closure. Generates authorization numbers for payment purposes, for all Inpatient or Partial services as determined in the review process.
Applies company authorization process (Milliman standards, policies, procedures, and contractual agreements) to submit information. Authorizes services in accordance with medical and health guidelines.
Coordinates with the referral source if there is not sufficient information available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows a process for requesting additional information.
Provides timely verbal/email/fax organization determinations to the requesting provider and/or members as per policy. Submits appropriate documentation/clinical information to clerical support for record keeping, mailing notifications, and documentation requirements.
Recognizes opportunities for referrals to Behavioral Health Case Management and refers accordingly. Identifies quality concerns through the review process and refers them to Quality Department for further investigation.
Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS), NCQA, URAC, and guidelines set forth by other regulatory agencies & HIPAA where applicable; obtains necessary professional and continuing education required for licensure and any applicable certifications.
In addition, all other duties are assigned by the manager and/or supervisor.

Requirements

Master’s Degree in a Behavioral Health field or Bachelor’s Degree in Nursing.
Current, unrestricted clinical license(s) to practice in Puerto Rico territory.
Minimum 2 years’ experience in a Clinical, Behavioral or Managed Care field preferred.
Personal computer experience should include working with Microsoft Word, Excel, PowerPoint and
Outlook at the intermediate level at a minimum.
Strong knowledge of behavior principles, chronic illnesses, and disease management.
Strong telephonic assessment and customer service skills.
Knowledge of community-based resources.
Knowledge of clinical assessment and crisis intervention.
Personal computer experience should include working with Microsoft Word, Excel, PowerPoint, and Outlook at the intermediate level at a minimum.

EEO
“Somos un patrono con Igualdad de Oportunidades en el Empleo y tomamos acción afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimentos.”