SALARY: Grade/Step is determined by qualification and experience of candidate. Position is full-time hourly with comprehensive benefits. The salary range for this position is $85,000-125,000. This position is exempt from overtime compensation.
GENERAL STATEMENT OF JOB: The Psychologist - UM Clinical Director is responsible for providing clinical oversight and direction for all Utilization Management and Member Appeals functions for covered populations. Duties include management and oversight of all UM staff to insure adherence to Vaya policies and procedures in conduction of service plan reviews, authorizations and appeals. Responsibilities include maintaining current operations as well as preparation for and implementation of Tailored Plan services with knowledge and understanding physical health care management. All functions must be in continuous compliance with UM Plans, external accreditation standards, and contractual requirements for Medicaid and state-funded consumers with Mental Health/Substance Use (MHSU) and Intellectual and Developmental Disabilities (IDD).
The Psychologist, - UM Clinical Director reports directly to the Chief Medical Office (CMO), and in collaboration with the CMO, develops and provides all internal clinical training, consultation and supervision, and ensures all funded external training meets the strategic goals of the department.
ESSENTIAL JOB FUNCTIONS: Oversight of Utilization Management Functions: •Participate in policy development and ensure monitoring and training of staff to ensure compliance with policies and accreditation standards are met. •Ensure consistent application of decision making criteria by Utilization Management staff and accreditation standards are continuously maintained. •Identify clinical needs and concerns and collect and monitor over and under-utilization data, with subsequent implementation of appropriate action in collaboration with relevant Vaya departments and stakeholder group. •Provide education and support to other Vaya departments about authorizations, denials, appeals, claims and clinical issues. •Review assigned performance indicators with monthly report to the Executive Leadership Team (ELT), and implementation of necessary corrective action measures.
Supervision and Consultation: •Provide clinical and administrative direction and support for the MH/SU and I/DD Utilization Management Clinicians, Support Staff, and their respective teams, ensuring adherence to established policies and procedure. •Educate staff on the interface of behavioral and physical health care and complex care management. •Support consistent application of clinical decision-making tools and criteria by Vaya staff and contractors •Ensure realistic staff performance standards are maintained and measured, with ongoing coaching and accurate performance documentation.
Peer Reviews: •Complete a minimum of 10 Peer Reviews per month with a focus on complex physical health - I/DD referrals and identified Resource Allocation issues, with evaluation of documentation for Medical Necessity. •Participate in mediations and administrative hearings related to Member Appeals as indicated. •Provide feedback to ELT on observed trends and concerns.
UM Planning and Monitoring: •Ensure ongoing compliance with internal and external regulatory standards during current operations and in the future with Tailored Plan functions •Ensure consistent application of decision making criteria by UM Clinicians •Review performance indicators, identify clinical needs/ concerns and monitor and collect data to develop corrective actions, including collaboration with other Vaya departments and stakeholders to address identified issues •Participate in design and implementation of Clinical Quality Improvement Projects
Facilitate Development of Provider Network: •Identify and document service gaps and deficiencies in access to services •Consult with and educate providers about Vaya service authorization requirements, evidence-based practices and other components to quality service provision •Identify provider training needs; provide training as needed and requested •Provide consultation to providers and Care Managers as requested regarding difficult and high-risk complex care cases •Collaborate with Population Health and Provider Network staff to improve services to complex care members
Other Duties: •Other duties as assigned by CMO.
QUALIFICATIONS & CREDENTIALING REQUIREMENTS: Doctoral degree in Psychology from an accredited institution of higher learning. Five or more years provision of direct patient care. Five or more years of experience in Utilization Review and Management for persons with serious mental health disorders, intellectual/developmental disabilities and substance use disorders. Must hold an active, unrestricted doctoral level psychology license in North Carolina.
KNOWLEDGE, SKILL & ABILITIES: This position requires exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts and established processes. Problem solving, negotiation and conflict resolution skills are essential. The UM Director must be able to independently organize multiple tasks and priorities, and to effectively manage these under pressure of deadlines. Thorough knowledge of behavioral health and I/DD principles, techniques, and practices, and their application to complex treatment and service provision is essential. The UM Director must have the ability to engage providers in collegial discussions about plans of care and best clinical practices for members as well as the ability to interact professionally and effectively with persons who disagree with UM decisions. The Psychologist - UM Clinical Director must be able to express ideas clearly and concisely orally and in writing, and to plan and execute work effectively and efficiently.
PHYSICAL REQUIREMENTS: Person in this position is required to have close visual acuity to perform activities such as preparation and analysis of data and figures; viewing a computer terminal; and extensive reading. Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers. Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
Internal Number: 1058
About Vaya Health
Make a difference while living in the mountains of NC
At Vaya Health, caring for our community is more than just a business opportunity: It’s the reason we exist. It is also the reason that our employees find their work meaningful and rewarding. We are committed to building communities where people can get the help they need to live the life they choose, and are looking for talented professionals to join us in this mission. If you share our passion for ensuring access to quality healthcare for the individuals and families in our region, contact us today so that, together, we can build a healthier western North Carolina.
Why Work for Vaya Health?
Vaya Health offers many career paths and opportunities. Our team is talented, knowledgeable, dedicated and caring. What’s more, we deeply value the skills and knowledge you have developed during your career. We work together to best assist the people in our communities who are facing significant challenges related to substance abuse, mental illness and/or intellectual/developmental disabilities.
In addition to competitive salaries and opportunities for advancement, employees are offered a wide range of benefits to meet their ind...ividual needs. These include:
?-Medical, Vision and Dental Insurance
?-Vacation and Sick Leave
?-Flex Spending Plans