Behavioral Health Navigator - Bilingual Spanish / Job Req 788830807

PRINCIPAL RESPONSIBILITIES:

The BH Navigator will assist with utilization management of services and monitor continuously for quality and accuracy. This role is responsible for processing and monitoring the authorization process and corresponding documentation.

Under the general direction of the Behavioral Health Supervisor, this position will help to plan, organize, and implement Alliance Behavioral Health program. The BH Navigator will support clinical staff through completion of the administrative components of Utilization Management (concurrent, urgent and routine pre-service, as well as retrospective authorizations) and Case Management (authorizations, basic care coordination). This position exercises considerable discretion and independent judgment in the performance of duties and responsibilities.

Principal responsibilities include:

• Work closely with licensed and unlicensed staff to co-manage tasks with individual members and navigate complex patients with mental health disease to access care.
• Works with licensed staff to ensure best practices for all relevant clinical areas of BHT/ABA and behavioral health.
• Works closely with Member Services to coordinate member access to timely and appropriate care.
• Works to clarify issues regarding a member's status, needs, and goals.
• Reviews activities including progress and barriers towards goals, resolves conflicts or strategizes solutions and adjusts current service plans as needed.
• Develops and prepares reports to meet internal, regulatory, contractual and accreditation requirements.
• Establish, facilitate and maintain effective ongoing relationships with network delegated groups, vendors and providers; facilitate communication and care coordination between network entities
• Utilize established UM guideline pathways for screening, authorizing, and finalizing authorization (inpatient, outpatient, retrospective) requests.
• Work with the Behavioral Health Manager, Senior Director of BH, Senior Medical Director, UM Management and clinical staff as well as other departments at the Alliance to receive, date, document and resolve Behavioral Health related inquiries/issues for claims, authorizations, appeals and eligibility. Perform these duties in a professional and timely matter.
• Accurately interpret and communicate member benefits and serve as resource for nurses and the IT Department in verifying and resolving member eligibility.
• Respond to provider, member, and staff inquiries at any given time in a professional and timely manner.
• Work closely with clinical personnel to better understand the reasons for modification, deferral, or denial of an authorization request.
• Maintain, coordinate, and prioritize authorizations to BH Clinicians and BH nurses, vendors, and hospitals in a timely manner as needed.

• Develop a partnership with community mental health entities that establish processes and protocols for inter-agency communication, referrals, and treatments for members.

• Collaborating with Credentialing and provider services for COC requests, and processes and providing education and follow-up on the member.
• Manage incoming Behavioral Health (BH) calls from the Behavioral Health and ABA call queue.
• Follows Behavioral Health guidelines and protocols in coordinating with the Behavioral Health Department staff.
• Continuously monitoring daily aging reports to ensure that TAT is met, and the Behavioral Health Department stays within the guidelines and policies set by the state.

• Manage the prior authorization queues and ensure the TAT is met.
• Providing Care coordination to the members and providers
• Investigating and responding to G&A cases by opening care coordination/ CM referrals. Providing outreach to the members to ensure services have been rendered and provide additional assistance.
• Obtained case history and gathered triage information to determine appropriate avenues for care.
• Providing answers to providers that are seeking in-network credentialing status and information.
• Involve other departments in project planning and implementation.
• Supports others in the BH department and provides help and assistance when possible.
• Regularly attends and participates in team and or departmental meetings and activities.
• Participated in non-clinical audits and report findings in various reports to send to compliance for review.
• Collaborate and communicate with management on issues and processes that impact Care Management and other organizational entities internally and externally.
• Coordinates member's behavioral and social service needs both within and outside AAH to coordinate members' care.
• Collaborates and communicates with the member, conservators, authorized member representative(s), physicians/provider office staff, health networks, and other health care providers to support and accomplish goals identified.
• Serves as an advocate to assist in coordinating the members identified psychosocial needs, utilizing community resources and support when appropriate.
• Educate PCPs and clinical staff on the care management referral process.

• Complete other duties and special projects as assigned.

ESSENTIAL FUNCTIONS OF THE JOB:

• Communicate and coordinate with PCPs, specialists, hospitals, other providers, and internally.
• Communicate effectively, both verbally and in writing.
• Multi-task and prioritize.
• Provide administrative support.
• Perform writing, administration, and data entry into multiple systems.
• Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS:

• Constant and close visual work at desk or computer.
• Constant sitting and working at desk.
• Extensive typing using keyboard and/or mouse.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders, files, binders, and other objects weighing between 0 and 30 lbs.
• Frequent walking and standing.
• Occasional driving of automobiles.

Number of Employees Supervised: 0

MINIMUM QUALIFICATIONS

EDUCATION OR TRAINING EQUIVALENT TO:

• Bachelor's degree or equivalent work experience required. Academic major in health services or related field preferred.

SUBSTITUTION FOR ACADEMIC MAJOR:

• Year over year full time experience may be substituted for the academic major (up to 4 years) when administrative duties are performed in a health service agency or program.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• One year experience in managed care or health care setting preferred.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• The ability to speak and understand-bilingual: Spanish/English, Cantonese/English, Mandarin/English, Vietnamese/English, Tagalog/English, Arabic/English are required as designated.
• A bilingual proficiency exam will be administered to ensure the candidate possesses the appropriate skill level to meet requirements. The successful candidate must score 90% or higher.
• Strong verbal and written communication skills.
• Ability to work within guidelines and protocols to achieve decisions independently.
• Critical thinking and problem-solving skills.
• Ability to work in cooperation with others.
• Ability to prioritize multiple projects as well as work for several other employees.
• Knowledge of and experience with California Children's Services (CCS) is a plus.
• Experience working with people with complex health needs preferred.
• Ability to act as resource to department staff.
• Working ability with Microsoft Office suite.

SALARY RANGE $34.80 - $52.21 HOURLY

The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.