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

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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

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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

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Agency Utilization Management Preparation Check List

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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

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Check List

Area Yes/No If “No,” Action to be Taken by Agency Organizational Structure UM staff members are an active part

• f 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

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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

• r SUD), Physical Health, HCBS (In house-
• utsourced-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 MCO’s requirements

Utilization Management Staff Supervisor Position Description

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UM Supervisor Responsibilities

• Provides day-to-day supervision of the

Utilization Management staff such as making case assignments, and assuring coverage for UM upcoming

• reviews. Provides weekly supervision

at a minimum.

• Holds case conferences to review

cases and develop strategies to manage these cases effectively.

• Reviews records to assure that care

plan strategies, transition strategies and documentation meets agency expectations.

• Periodically listens to the calls taking

place between the Agency UM staff and the MCO Agency staff to assure appropriateness of the conversations.

• Maintains routine and productive

channels of communication with the MCO UM Departments with which the agency contracts. Seeks feedback on the work of the agency.

• Maintains understanding of current UM

practices and related expectations for each MCO with which the agency works

• Trains the UM staff on current UM

practices

• Develops internal workflows (including

tools and schedules) with clearly designated responsibilities to support efficient and timely reviews

• Continually looks for process

improvement opportunities

• Member of the agency’s leadership

team

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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

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UM Supervisor Qualifications

Utilization Management Staff Position Description

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• 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
• pinion.
• 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

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UM Staff Responsibilities

• 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

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UM Staff Qualifications

Q & A

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Upcoming Events

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June

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

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

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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

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