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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