JOB DESCRIPTION

TITLE:    SENIOR DIRECTOR OF BEHAVIORAL HEALTH UM/CM                GRADE: 12

REPORTS TO:  EVP of Customer Delivery                                                     STATUS: Exempt

SUPERVISES:  All clinical operations Staff and Supervisors for Behavioral Health

APPROVED BY: EVP of Customer Delivery                                      DATE APPROVED:  2/2008

HUMAN RESOURCES:  Senior Director of Human Resources       DATE REVIEWED:   2/2008

JOB SUMMARY:  The Senior Director of the Behavioral Health Utilization Management and Case Management department is responsible for assisting in the development and implementation of operational and functional support for Behavioral Health Utilization Management and Case Management activities.    This position (1) directs and coordinates the operations of all behavioral health activities to ensure compliance with policy and procedures, accreditation, and regulatory standards; (2) provides direction to Information Services development/management; (3) provides direction in regards to the impact on the behavioral health department to the  appropriate departments to support the development and launching  of new programs; (4) collaborates  with clients and account management to deliver quality products and provide excellent customer service; (5) assists product development/management, marketing and sales with the development of product collateral and RFP responses; (6) participates in presentations for prospective clients and existing clients (7) oversees the management responsible for managing all behavioral health inbound and outbound call center functions to meet performance and quality standards; (8) oversees the management responsible for managing productivity, timeliness and quality for all behavioral health authorization requests; (9) oversees the management responsible for behavioral health productivity, timeliness and quality of case management activities; (10) responsible for adhering to budgetary constraints and effectively utilizing resources to manage the day to day operations of the behavioral health department; (11) works in collaboration with the Behavioral Health Medical Director and the Executive Vice President of Customer Delivery  to track and trend under and over utilization of behavioral health services to identify opportunities for improvement, followed by implementation of policies and procedures to initiate and monitor the impact the behavioral health utilization management and case management activities; (12) collaborates with the Vice President of Customer Delivery to ensure that the complete process for the behavioral health authorizations process from start to finish – entering of demographics, obtaining and processing clinical information, through the physician review process, for the cases that are reviewed by a physician, -  meets timeliness standards; (13) collaborates with the Vice President of Synergy and the Director of Medical Management to coordinate care for members who have access to all of our Health Integrated programs.   

MINIMUM QUALIFICATIONS: 

Education:              License Registered Nurse with a current, unrestricted license.    Additional certification in area of specialty and/or case management preferred. Bachelor’s or Master’s Degree preferred.

Experience:            Minimum of 5 years experience in managed care at the manager level or above with experience managing utilization management and case management staff. Minimum of 5 years clinical experience, with a combination of medical and behavioral health experience. Minimum of 5 years experience in the application of criteria systems, such as internally developed criteria, Milliman criteria or InterQual criteria.   

Knowledge/skills:          

• Ability to develop and execute product plans, including identification of resources and budget required.
• Excellent communication skills, both verbal and written;
• Ability to direct and coordinate programs, projects, resources, and staff across multiple company functions.
• Strong analytic qualities to analyze goals, products, programs, and processes and make recommendations for changes.
• Knowledge of managed care, utilization management, case management, and disease management.
• Organizational and project management skills.
• Experience working with clinical documentation programs designed for utilization management programs.
• Personal computer skills in Windows, WORD, EXCEL, Access, PowerPoint, and clinical documentation.
• Ability to manage inbound and outbound call center functions to meet established productivity, performance, and quality standards.
• Strong communication, interpersonal and leadership skills.
• Call center knowledge desirable.

ACCOUNTABILITIES:

              Job Performance/Responsibilities

              Coordinates and directs all Behavioral Health Utilization Management

• Assures job descriptions and staff roles/responsibilities are accurate and current;
• Responsible for the hiring and professional development of the manager and supervisor within the department, as well as oversight of the hiring and development  of individual staff who work within the Behavioral Health department who report to either the supervisor or manager.
• Assists in the licensing and accreditation process for all programs;
• Assures that all regulatory and accreditation standards are implemented and followed.
• Assures that Policies & Procedures, Operational Guidelines, and process workflows remain current, meet quality accreditation and regulatory standards, and are communicated to and available for staff to utilize.
• Develops the annual utilization management and case management program descriptions in conjunction with the Director of Medical Management
• Develops the annual work plan & summary for behavioral health utilization management and case management programs in conjunction with the QI committee (includes goals, objectives, and planned new processes/enhancements, and communicates the annual work plan and previous year’s summary to management and staff.
• Assists the Quality department in the development of an annual QI plan for all programs and assures all indicators are met;
• Participates in the Quality Committee and assists in related functions;
• Analyzes all programs to ensure effectiveness, quality, productivity, and profitability and patient safety;
• Coordinates all programs and work with other Health Integrated Departments and Committees, i.e. Quality Committee, Education, Account Management, etc;
• Assists in new product development efforts and assures current products are being delivered as designed;
• Assists the Vice-President of Clinical Operations in plans for growth;
• Provides feedback and direction to Information Services on systems issues and enhancements;
• Offers feedback and assists in the identification and development of education and training programs;
• Assures delivery expectations of client contracts are being met; 
• Assists in the development of management reporting capabilities and works with management to ensure they understand and use them to effectively manage the delivery of services; and
• Provides required reports and special projects as needed.
• Readily available to answer questions and shall ensure non-clinical administrative staff is performing within the scope of the non-clinical role.
• Works directly with the Medical Director on program delivery

              Customer Services-Internal:

• Responsible for developing and maintaining a high level of morale within the department
• Responsible for providing leadership and sharing the goals and objectives of Health Integrated as an entity and those of the department with the Behavioral Health staff.
• Responsible for the professional development of the Behavioral Health management staff and providing direction for the individual development of its front-line clinicians
• Responsible for the development and implementation of a career ladder for the department.
• Responsible for the identification and resolution of problems/issues/concerns within the department.
• Responsible for developing a strong working relationship with the Behavioral Health staff and with all of HI’s internal management team to encourage a cooperative sharing of ideas and support.
• Monitors and reports any quality of care issues or concerns to Quality Mgmt;
• Holds regularly scheduled team meetings with staff.
• Actively participate in the Touch Base weekly team meetings.

Customer Service-External

• Works collaboratively and communicates in a harmonious, courteous and professional manner with members, practitioners, providers, multidisciplinary health care team members, and clients.
• Works collaboratively with the health plan’s management team to assure quality service delivery that meets client expectations. and
• Serves as a liaison and patient advocate, when applicable, for quality of care and cost outcomes.

PHYSICAL/MENTAL ESSENTIAL JOB FUNCTIONS:

The number next to each item indicates the frequency that this activity occurs:

1) Occasionally: 1% to 33% of work time            2) Frequently: 34 to 66 % of work time 3) Constantly: 67 to 100% of work time

LIFTING

3                              Between 0 and 5 pounds

2                              Between 5 and 10 pounds

1                              Between 10 and 20 pounds

0                              Between 20 and 50 pounds

0                              Between 50 and 80 pounds

0                              Over 80 pounds

MOVEMENT

3               Sitting

1                              Standing

0               Bending

1               Walking

0                              Pushing

0               Pulling

1                              Carrying

0                              Crouching

0                              Kneeling

0                              Crawling

0                              Squatting

ENVIRONMENT

3                              Challenging situations

0               Exposure to trauma and grief 

                 2               Noises and other distractions

                 0               Dust and fumes

0               Fluctuations of indoor heat and cold

0                              Working on an uneven terrain

VISUAL

3               Depth perception

3               Reading close-up work

1               Peripheral field of vision

3                              Color differentiation

REACHING-Above Shoulder Level

3               Between 0 and 5 pounds

2               Between 5 and 10 pounds

1               Between 10 and 20 pounds

0               Between 20 and 50 pounds

0               Between 50 and 80 pounds

0               Over 80 pounds

DEXTERITY

3               Simple grasping

2               Firm grasping

3               Fine manipulation

OPERATING EQUIPMENT

3               Office machines

3               Telephones

3               PCs

1               Driving

Other:

SPEAKING/HEARING

3               Hearing normal speech

3               Hearing garbled or electronic speech

3               Hearing telephone conversations

3                              Conducting telephone conversations

2               Hearing faint sounds:

ACKNOWLEDGEMENT:

As an employee of Health Integrated, employed in this job described in this document, my signature indicates that I have read and understand the duties, responsibilities and expectations of performance either explicitly described or implied in this document.  My signature indicates that I have disclosed any accommodations necessary to perform the essential job functions of this position.  This job description is not a contract for employment.  I understand that my employment with Health Integrated is at will:              

_____________________________          ________________

Employee Signature                                     Date