Utilization Specialist

Primary Responsibilities and Duties

Community Supports:

• Obtain and utilize working knowledge and maintain accountability for program standards in respective catchment areas listed below and others as they become applicable:
  • PASSE systems
  • HCBS
  • DDS
  • DCFS
• Maintains day to day working knowledge of all operational and Community Supports (CS) procedures.
• Develops and maintains positive, cooperative relationships with the community, such as but not limited to, schools, civic groups, and social agencies.
• Attends meetings with stakeholders (customers, guardians, advocates, etc.) as needed in the setting of their choice.

Utilization Management:

• Identify, analyze, and evaluate customer utilization and obtain a plan to correct budgetary problems by ensuring that all customers have the correct number of units required for billing.
  • Oversees and maintains Rate Comp Workbooks (RCWB) submissions for their designated case load.
    • Ensures submission of Prior Authorizations (PA) to ICM’s Billing Specialist two weeks prior to the PA end date.
    • Train managers on the organization’s utilization, metrics, prior authorizations, billing, and any other needed items for upkeep of Supportive Living Budgets.
    • Provide managers with weekly Utilization audit.
      • Follow up with managers to ensure that all findings on the weekly audit are rectified in a timely manner.
    • Provide report to ICM’s Finance team during each Monthly Utilization meeting on respective caseload’s findings on Monthly Utilization report.
  • Work interdepartmentally to ensure that utilization is maintained within all programs.
  • Will assist with managing and overseeing utilization for the BRAVO, Autism and Senior Care programs.
  • Will work in coordination with the Scheduling and Administrative Coordinator to ensure that all Prior Authorizations are requested and received within two weeks prior to the prior authorization end date.
  • Including but not limited to:
  • Unit cost
  • Ancillary budgets
  • Budget Summary
  • Submission Memo
  • Submits RCWB to Finance and Administration for review via folder structure in Teams.
  • Assists with completion of assessments as needed. (ex: Risk, Functional, etc.)
  • Submits the following to PASSE, following specific PASSE procedure (submission items may include):
  • Submission Memo
  • Budget Page
  • Current PCSP
  • ISP Program from Therap (in pdf format)
  • Risk Assessment
  • Functional Assessment
  • Psychological Exam
  • Behavioral reports (if applicable)
  • Incident reports (if applicable)
  • Any other documentation that would assist in plan submission (i.e., doctor visit forms, etc.)
  • Reviews the RCWB submissions to ensure the correct units for submission are reflected.
  • When overages occur in the proposed budget, the Administrative Coordinator will work with the Utilization Specialist to request approval through the Chief Financial Officer (CFO) to proceed with the plan.
  • Will work in collaboratively with the Community Supports Managers (CSM) team when new positions or revisions are made to the RCWB.
  • Tracks and submits all Prior Authorizations to the Billing Specialist.
  • Other duties as assigned.
  • Personal Outcome Measure (POM) Interview:
    • Completes training to conduct Personal Outcome Measure (POM) interviews.
    • Completes POM Interviews.
    • Reports findings back to ICM’s Co-Chief Operating Officers.
  • Training
    • Promotes a team approach by providing team members with honest and motivational feedback and assists with problem solving as needs arise.
    • Identify key responsibilities, skills and assess and strengthen the program to achieve outcomes and design intervention strategies when needed.
    • Provide support and training for new employees.
      • Assuring that the quality of supports is the top priority.
    • Facilitates New Employee Orientation (NEO) as needed.
      • Obtains certification as a CPR instructor to be available to facilitate classes as needed.
      • Assists with implementation and training of Positive Behavior Support Plans as needed.
    • Audits:
      • Completes random audits to assure that all regulations and standards are met.
      • Approves and monitors all required assessments for their designated caseload.
    • Oversite:
      • Oversees and maintains all aspects of assigned specialized programs, including but not limited to Foster Care and various consultants (behavioral health, nursing, etc.).
      • Assure that work is accurate and that it conforms to program standards, maintain priorities while meeting deadlines and maintaining a smooth workflow.
    • Consultations:
      • Submission of consultation and equipment requests as needed.
        • Provides follow-up to assure that requested consultation/equipment is received by the respective customer.
      • Works directly with consultants to assure that consultations are coordinated effectively.
    • Miscellaneous Duties:
      • Obtains/maintains Notary Public to be able to sign off on required documentation.
      • Participating in marketing events as the opportunity arises.
      • Oversee and assist with special projects.
      • Understand and comply with HIPAA (Health Insurance Portability and Accountability) restrictions.
      • Maintains positive rapport and communication with all team members. Responds to all requests in a timely manner and assures that consistent communication is kept with their direct supervisor is kept.
      • Serves as an advocate for all stakeholders and works to assist customers with overcoming any barriers that they might encounter while respecting their personal beliefs, choices, and interests.
      • Be willing to travel within the state on as needed basis.
      • Will always adhere to ICM’s Employee Handbook and will abide by company, agency, and program policies and procedures and for acting in a manner consistent with organizational values, mission, and goals.
    
    

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Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)