Quality Care Management Coordinator

• Knowledge of California Mental Health Plan and Drug Medi-Cal Organized Delivery Systems including recently enacted laws tied to the Managed Care Final Rule and Drug Medi-Cal Organized Delivery System.
• Demonstrated ability to develop and maintain sound working relationships with people of diverse backgrounds and personalities.
• Experience in clinical and/or managed care planning and oversight.
• Strong background as a licensed mental health professional.
• Experience managing and monitoring regulations.
• Experience in utilization review.
• Experience and/or education in alcohol and other drug services.
• Excellent oral and written communication skills and the ability to interact with all levels of internal and external customers.
• Detail oriented while handling multiple projects with competing priorities.
• Organized and prioritize work, and meet deadlines.
• Processes, interprets and communicates complex contractual information to internal and external clients.
• Open to change and new information, and adapt behavior and work methods in response to new information, changing conditions, and unexpected obstacles.
• Bilingual skills in English/Spanish is highly desirable, but not required.

1. Develops and implements policies and procedures for the utilization review function to assure the effective utilization of medical or psychiatric services, and appropriate service reimbursement; reviews requests for authorization of services to determine whether the diagnosis and proposed treatment fall within the criteria for service reimbursement and authorizes treatment or refers the request to a higher medical authority; and authorizes reimbursement of contracted inpatient and outpatient services.
2. Collects and reviews statistics of services provided using automated systems to determine effectiveness and quality of care provided and to assess whether changes in the program are necessary to provide optimum health or psychiatric care in the most cost-effective manner; and generates reports from automated system.
3. Works with beneficiaries, providers, co-workers, and other public agencies to discuss or explain services provided or denied, give direction or authorization for specialized treatments, and establish eligibility of beneficiaries for services.
4. Collaborates with fiscal intermediaries, medical staff or mental health professionals, and others to review and interpret patient records and documentation when requests/claims for reimbursements are denied; writes narrative and statistical reports on utilization reviews; and prepares correspondence using word processing software.
5. Reviews state regulations; reviews policies and procedures and makes recommendations to management on methods to conform to regulations; educates staff on regulation changes; meets regularly with care providers to identify and address utilization review issues; and conducts training sessions for clinical and support staff on utilization review and documentation.
6. Assigns, reviews, and evaluates the work of professional, technical, and clerical staff.

Applicants must meet the employment standards (minimum qualifications) list below to be considered for this position. Detailed information should be included in the application.

1. Three (3) years of clinical experience as a licensed mental health professional as defined by California Code of Regulations, Title 9, Chapter 11, *1770 (including registered nurses, licensed clinical social workers, and marriage and family therapists). Work must have included some experience planning, organizing, and evaluating program operations and staff; OR,
2. Three (3) years of clinical experience as an ASW or MFT intern or other waivered/registered Point of Authorization staff as defined by California Code of Regulations, Title 9, Chapter 11, *1770 and 1820.200. Work must have included some experience planning, organizing, and evaluating program operations and staff; OR,
3. A combination of training, education, experience, and licensure or registration that is equivalent to one of the employment standards listed above and that provides the required knowledge and abilities.

APPLICATION & SELECTION PROCESS:

1. Review applications and supplemental questionnaire to determine those applicants who meet the employment standards.

1. Supplemental Questionnaire Ranking: Candidates' response to the required supplemental questionnaire will be evaluated and scored. Candidates' final score and rank on the employment list will be determined by their responses to the supplemental questionnaire. This process may be eliminated if there are fewer than eleven (12) qualified candidates.

• Live Scan and Background Check: Once a conditional offer of employment has been made, the selected candidate's appointment is contingent upon successful completion of a Live Scan and background check which includes a conviction history check, and satisfactory reference checks. A Live Scan is electronic fingerprint scanning that is certified by the State Department of Justice. Further instructions about when and how to complete the Live Scan will be included in the offer letter. Appointee will be subject to a post-offer medical evaluation or examination.
• The appointee must satisfactorily complete a one-year probationary period.
• Background Investigation: Finalists for positions in this class will be required to pass a pre-offer, job-related background investigation.