Behavioral Health Utilization Management Clinical Coordinator - Remote in Colorado

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The Clinical Coordinator is responsible for processing all Behavioral Health and Substance Use Disorder authorizations within designated turnaround times for various lines of business, including RMHP DSNP, RMHP Medicare, RMHP PRIME Medicaid, RMHP RAE Medicaid, RMHP CHP+, RMHP IFP, and NHP RAE Medicaid. This role involves applying approved medical necessity criteria, escalating cases to secondary medical director review when necessary, and collaborating with leadership and medical directors on complex cases.

The Clinical Coordinator proactively manages and identifies potential barriers for members, ensuring they receive necessary care and support. They refer members to the RMHP Care Coordination Department for specific needs, notify providers and requestors of authorization determinations, and offer peer-to-peer consultations when cases do not meet criteria. Additionally, the Clinical Coordinators draft denial letters, validate eligibility, input authorization requests into electronic health records, and provide assistance to callers.

They complete required trainings, participate in annual Inter-Rater Reliability testing, and facilitate care coordination meetings. The role also involves engaging members in the RMHP Contingency Management Program, collaborating with facility staff, providing consultations, maintaining confidentiality, supporting evidence-based practices, establishing and maintaining professional relationships, identifying the need for higher-level reviews, formulating case overviews, administering benefits, handling escalated calls, and applying clinical knowledge to determine medical appropriateness.

You’ll enjoy the flexibility to work remotely
* from anywhere within the U.S. as you take on some tough challenges. Remote in Colorado preferred.

• Process all Behavioral Health and Substance Use Disorder authorizations submitted by providers within the designated turnaround times specified in the Prior Authorization List for all lines of business, including RMHP DSNP, RMHP Medicare, RMHP PRIME Medicaid, RMHP RAE Medicaid, RMHP CHP+, RMHP IFP, and NHP RAE Medicaid
• When processing authorization requests, the Clinical Coordinator applies approved medical necessity criteria and appropriately escalates cases to secondary medical director review when necessary
• Collaborates with leadership to discuss authorization requests when additional guidance is required
• Proactively manages and identifies potential barriers for members, activating appropriate entities and departments to ensure members receive the necessary care and support to stabilize
• Collaborates with the medical director on complex cases to ensure members receive appropriate treatment
• Refers members to the RMHP Care Coordination Department when specific needs are identified, ensuring they are addressed to facilitate successful aftercare planning
• Notifies providers and requestors of all authorization determinations
• When a case is determined not to meet criteria, corresponds with the requesting provider to offer a peer-to-peer consultation with the RMHP medical director, allowing the provider to present additional information before a final decision is made
• When a medical director issues a denial, the Clinical Coordinator drafts a letter informing the member and the requesting provider of the decision, the reasons for the decision, and offers alternative treatment options
• Verifies eligibility of providers and members for all authorization requests
• Inputs authorization requests into an electronic health record
• Promptly provides assistance to callers routed to the BH UM department
• Completes required trainings by the assigned due dates to comply with auditing entities such as NCQA. These trainings include, but are not limited to the…