Job description

We are hiring IMMEDIATELY for a REMOTE Behavioral Health Specialist to join one of our community mental health providers!

*$2,000 SIGN-ON BONUS*

*FULLY REMOTE - MUST LIVE IN OREGON*

Summary: The Behavioral Health Specialist for Appeals and Grievances applies clinical knowledge in administering appeals and grievance activity. is responsible for adhering to all State and Federal regulatory requirements as relevant to grievances and appeals. This position coordinates and acts as a resource for grievance coordinators and appeals coordinators during the routine processing of both components. Additionally, this position works closely with department leadership to identify opportunities or assist in strategies toward for process improvement.

Essential Position Functions

Clinical Administration

• Using behavioral health clinical expertise, medical necessity criteria, review of clinical record, and consultation with Medical Director, make determinations on member appeals of denied services or grievances filed against providers.
• Work with Grievance and Appeals Coordinators to ensure that service requests, authorizations, and complaints are managed in accordance to the OHP/DMAP/Medicare rules on direction of the Quality Assurance Manager.
• Work closely with the Quality Improvement Manager to ensure clinical issues are addressed in a timely and thorough manner
• Collaborate with Behavioral Health leadership to ensure alignment of appeals and grievances with Behavioral Health strategies, initiatives, and best practices.
• Maintain accurate and complete documentation for files related to grievances and appeals.
• Communicate with members and providers, both verbally and written, to effectively administer grievances and appeals; provide status updates as needed.
• Ensure that authorization decisions are based on coverage rules.
• Coordinate and facilitate risk reduction strategies for quality and patient safety issues when opportunities are identified.
• Support QI Manager in assembling all relevant evidence for DMAP hearings or Maximus review.
• Provide clinical expertise to other department members in evaluation of program outcomes, providing input for program activities.

Regulatory Compliance

• Coordinate and participate in periodic audits, overall quality management and improvement activities, and other regulatory and accreditation activities, this may include participation in the analysis and summary of data for written reports and public presentations.
• Maintain confidentiality of all discussions, records, and other data in connection with quality management activities according to professional standards.

Knowledge, Skills and Abilities Required

• Knowledge of or the ability to learn the Oregon Health Plan and Medicare A and B benefit packages
• Ability to use medical necessity criteria, such as Interquel or other nationally recognized criteria, and/or other regionally based clinical guidelines
• Full ability to apply and understand the DSM 5
• Knowledge of DMAP rules and regulations as it pertains to utilization management, medical necessity, and member rights and responsibilities, especially as pertaining to member/patient appeals and grievances rights
• Knowledge of or ability to learn ICD-10, CPT and HCPCS codes
• Ability to independently manage and prioritize multiple tasks with varying degrees of acuity
• Ability to work autonomously, including meeting varying work task turnaround times independently
• Ability to collaborate with community providers including facility staff
• Knowledge of principles, methods, and procedures for diagnosis, treatment, and rehabilitation of physical and mental dysfunctions
• Knowledge of human behavior and performance; individual differences in ability, personality, and interests; learning and motivation; psychological research methods; and the assessment and treatment of behavioral and affective disorders
• Ability to use logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
• Ability to identify complex problems and review related information to develop and evaluate options and implement solution
• Ability to use critical thinking skills in problem solving
• Strong written and verbal communication skills
• High degree of initiative and motivation along with the ability to effectively collaborate and plan with coworkers and others.
• Ability to work in an environment with diverse individuals and groups
• Basic word processing skills

Education and/or Experience

Required:

• Master’s degree in Social Work, Addictions, or Counseling
• Minimum 2 years’ experience in behavioral healthcare direct clinical practice

Preferred:

• Experience in specialty behavioral health and/or a comparable position in quality assurance
• Experience with health plan operations or managed care work, or have managed the receipt and processing of member or client/patient Appeals and Grievances
• Experience or knowledge in administration of the Oregon Health Plan and/or Medicare, per CMS guidelines
• Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Certified Alcohol and Drug Counselor (CADC II or III) helpful

"Careers and companies flourish when staff, clients, and candidates truly believe in the mission, know the role they play, and humbly reflect, evaluate, and act for the best interest of the communities served".

Proof of COVID-19 vaccination.

Job Type: Full-time

Pay: From $75,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible schedule
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Relocation assistance
• Retirement plan
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Supplemental pay types:

• Signing bonus

Education:

• Master's (Required)

Experience:

• Behavioral health: 2 years (Required)
• administering appeals and grievance: 2 years (Required)

License/Certification:

• LCSW, LPC, OR CADC? (Preferred)

Work Location: Remote

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