Behavioral Health Nurse Navigator

POSITION SUMMARY:

The Behavioral Health Nurse Navigator strives to improve member health and assure optimal navigation of behavioral health and substance use disorder (SUD) services, including co-occurring physical health needs. The Behavioral Health Nurse Navigator conducts preservice, admission, concurrent and retrospective reviews for level of care and length of stay for behavioral health and SUD services across inpatient psychiatric, crisis stabilization, residential, partial hospitalization, intensive outpatient and other outpatient services. The position coordinates and integrates behavioral health services that require prior authorization, facilitates discharge planning in collaboration with facility staff, and maintains authorizations with required data and pertinent clinical information. The Behavioral Health Nurse Navigator acts as a liaison between members, providers and The Health Plan's interdisciplinary care team, advocating for members who require coordinated care and connecting them to case management, transition of care, community and other programs to promote continuity of care, recovery and optimal outcomes within the managed care system.

QUALIFICATIONS REQUIRED: (Education, Experience, Skills)

• Registered Nurse with a minimum of three (3) years of clinical experience, including at least two (2) years in a behavioral health, psychiatric and/or substance use disorder setting.
• Active, unencumbered Ohio and West Virginia RN licensure (or the ability to obtain both by the end of the 90-day probationary period), which must be maintained throughout employment, including compliance with State Boards of Nursing continuing education requirements. Other licensure as company expansion warrants.
• Working knowledge of behavioral health levels of care, psychiatric and SUD treatment modalities, and community behavioral health resources.
• Excellent oral, written, telephonic and interpersonal communication skills.
• Proficient keyboarding skills and computer literacy with the ability to navigate multiple systems, including Microsoft Office programs (Word, Excel, Outlook).
• Ability to exercise independent and sound clinical judgment in decision making, utilizing all relevant information with proactive identification and resolution of issues.

QUALIFICATIONS DESIRED: (Education, Experience, Skills)

• Utilization Management, Case Management, Quality Improvement or other managed care experience with a payor organization.
• Familiarity with InterQual and ASAM criteria for behavioral health and SUD level-of-care determinations.
• Certification in area of clinical expertise, such as Psychiatric-Mental Health Nursing (PMH-BC), Certified Case Manager (CCM), Certified Addictions Registered Nurse (CARN) or Motivational Interviewing.
• Flexibility and ability to multi-task, work in a fast-paced environment and adapt to changing processes, balancing independent and teamwork.
• Superior work ethic and commitment to excellence and accountability.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

• Conducts timely admission, concurrent and retrospective reviews of behavioral health and SUD services (inpatient psychiatric, detoxification/withdrawal management, crisis stabilization, residential, partial hospitalization, intensive outpatient and other outpatient services) for medical necessity, level of care and length of stay using The Health Plan's approved criteria.
• Reviews and processes behavioral health prior authorization requests, referring cases that do not meet criteria to the Medical Director/Behavioral Health Physician Reviewer for determination in accordance with UM policy.
• Reviews and evaluates relevant information, including member history, medical records, benefit design, plan limitations, exclusions, coordination of benefits and member eligibility, in making recommendations consistent with sound clinical and managed care practice.
• Collaborates with facility utilization review staff, discharge planners, attending providers and the member/supportive others to facilitate safe, timely discharge plans, including follow-up appointments within seven (7) days of discharge from inpatient behavioral health care.
• Identifies high-risk members (e.g., frequent readmissions, co-occurring conditions, suicide risk, social determinants of health needs) and refers them to Behavioral Health Case Management, Behavioral Health Transition of Care, Social Work or other appropriate programs.
• Coordinates with medical utilization management and case management teams.
• Identifies potential quality of care issues and variances and refers them to the appropriate department or manager.
• Identifies and reports potential high-cost cases through hospital review, referral requests or claims cost reports.
• Completes accurate and timely documentation of all reviews, contacts, determinations and interventions in The Health Plan's clinical platforms in compliance with NCQA, CMS and BMS regulatory standards and required turnaround times.
• Maintains productivity comparable to peers and monthly quality interrater scores at or above 90% using the departmental monitoring tool.
• Promotes communication, both internally and externally, to enhance the effectiveness of behavioral health management services.
• Prioritizes assignments appropriately and maintains flexibility as new priorities arise.
• Strives to improve quality in all areas of responsibility and cooperates with all departments to improve quality throughout The Health Plan; participates in quality improvement activities and serves on departmental or company committees as assigned.
• Reports any changes in licensure (e.g., application declined/denied; license revoked, suspended or lapsed; notification of an investigation by a licensing board; or disciplinary action) to the direct supervisor throughout the term of employment.