Utilization Management Webinar Series #2: Staffing for UM - PowerPoint PPT Presentation

Utilization Management Webinar Series #2: Staffing for UM

Presented By Boris Vilgorin Health Care Strategy Officer McSilver Institute for Poverty Policy & Research Silver School of Social Work New York University 2

LEARNING OBJECTIVES • Understand UM-focused staff positions • Learn from the experience of other organizations • Ask questions that help to clarify the way forward with UM Staffing 3

What is Utilization Management? • The process by which an MCO decides whether specific health care services, or specific level of care, are appropriate for coverage (to be paid) under an enrollee’s plan • Primary purpose of the program is to ensure that services are necessary, appropriate, cost-effective and at the least restrictive level of care • Utilization Review (UR) vs. Utilization Management (UM)  UR – Regulatory requirement, Internal review.  UM – MCO standards, External review • Maintain fidelity and integrity of service provision 4

Agency Utilization Management Preparation Check List 5

Agency Utilization Management Preparation Check List Categories in Check List • Agency Culture • Organizational Structure • Managed Care Organization Information • Agency Practices and Processes • All Agency Staff • UM Staff • Supervision • Technology • Quality Improvement 6

Check List Area Yes/No If “No,” Action to be Taken by Agency Organizational Structure UM staff members are an active part of the treatment team for services being provided, attend treatment team meetings and receive regular updates from all members, especially the Transition/Discharge Planners UM staff member work space is proximate to service delivery team to allow for timely and convenient communication 7

Check List Area Yes/No If “No,” Action to be Taken by Agency UM Staff Hire staff members with expertise in specialty being reviewed, e.g.: Behavioral Health (MH or SUD), Physical Health, HCBS (In house- outsourced-central-program specific) Orient staff to MCO UM language and provide practice opportunities Provide documentation received from the MCOs concerning UM expectations (HEDIS) Review and fully understand LOC criteria, continuing stay, and discharge criteria (LOCADTR for SUD) as well as any service volume caps Participate in case studies: Practice offering justification in a manner that reflects the 8 MCO’s requirements

Utilization Management Staff Supervisor Position Description 9

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UM Supervisor Responsibilities • Provides day-to-day supervision of the • Maintains routine and productive Utilization Management staff such as channels of communication with the making case assignments, and MCO UM Departments with which the assuring coverage for UM upcoming agency contracts. Seeks feedback on the reviews. Provides weekly supervision work of the agency. at a minimum. • Maintains understanding of current UM • Holds case conferences to review practices and related expectations for cases and develop strategies to each MCO with which the agency works manage these cases effectively. • Trains the UM staff on current UM • Reviews records to assure that care practices plan strategies, transition strategies • Develops internal workflows (including and documentation meets agency tools and schedules) with clearly expectations. designated responsibilities to support • Periodically listens to the calls taking efficient and timely reviews place between the Agency UM staff • Continually looks for process and the MCO Agency staff to assure improvement opportunities appropriateness of the conversations. • Member of the agency’s leadership 11 team

UM Supervisor Qualifications Qualifications: • RN, and/or licensure as a professional w/certification and/or expertise in specialty being reviewed, e.g.: Behavioral Health, Physical Health, Home & Community Based Services Experience with Utilization Management practices • • Values person-centered, recovery focused practices • Supervisory experience, including the ability to develop team performance • Demonstrated competency in the interpretation of UM metrics • Knowledge of MCO outcomes/requirements, e.g.: HEDIS Knowledge of what is unique to each MCO in their review process • • Excellent written and oral communication skills • Self-motivated, able to prioritize multiple issues, excellent organizational skills • Ability to track multiple projects/tasks and follow through as needed • Ability to manage and coordinate with internal and external departments Managed Care experience • 12

Utilization Management Staff Position Description 13

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UM Staff Responsibilities • Effectively communicates with MCO UM departments concerning agency cases under review • Maintains a positive and professional working relationship with MCOs UM Staff. • Maintains understanding of current UM practices and related expectations for each MCO with which the agency works. Professionally carries out practices • Effectively negotiates resolution when a case review results in a difference of opinion. Maintains excellent channels of communication with agency service delivery staff • • Participates in case conferences to review cases and to develop strategies to manage these cases effectively. • Reviews records to assure that care plan strategies, transition strategies and documentation meet MCO UM expectations. • Monitors UM information sent from MCOs to assure that any changes in UM practices are incorporated into the agency’s practices. • Continually looks for UM process improvement opportunities 15

UM Staff Qualifications • RN, licensure as a professional w/certification and/or expertise in specialty being reviewed, e.g.: Behavioral Health, Physical Health, Home & Community Based Services • Experience with Utilization Management practices • Values person-centered, recovery focused practices • Demonstrated competency in the interpretation of UM metrics Knowledge of MCO outcomes/requirements, e.g.: HEDIS • • Knowledge of what is unique to each MCO in their review process • Excellent oral communication skills • Self-motivated, able to prioritize multiple issues, excellent organizational skills • Ability to track multiple tasks and follow through as needed Ability to manage and coordinate with internal and external departments • • Managed Care experience 16

Q & A 17

Upcoming Events June Monday Tuesday Wednesday Thursday Friday 6/1-6/5 UM webinar- Effective UM HCBS training- Practices Syracuse Overview 6/8-6/12 UM webinar- 6/15-6/19 Staffing UM webinar- 6/22-6/26 Implementation UM webinar- Supervision Children's HOLIDAY Summit- Children's Summit- Albany 18 6/29-7/3 NYC

Please submit questions between sessions to: mctac.info@nyu.edu using the subject line ‘UM Overview Questions’ 19

Visit www.mctac.org to view past trainings, sign-up for updates and event announcements, and access resources. mc ta c .info@nyu.e du @CTACNY 20

Thank you for participating! Please visit http://www.ctacny.com/ and http://www.mctac.org/ to sign up for additional offerings and trainings. 21