JOB DESCRIPTION: UTILIZATION MANAGER

1 job description : UTILIZATION MANAGER . Job Summary o To oversee the implementation of Mosaic's UTILIZATION Management and UTILIZATION Review Plans. Responsibilities General: Adheres to all current federal & state laws, as well as Mosaic's Policies and Procedures, including the safeguarding of confidential healthcare information and compliance with the Health Insurance Portability &. Accountability Act (HIPAA). Reports immediately any suspected incidents of child abuse or neglect to the Child Abuse Hotline Establishes relationships and communicates with clients, caseworkers/probation officers, family members, and staff Identifies and seeks resolution for potential problems arising with staff or other involved parties Attends staff / agency meetings Completes other duties as directed by the Clinical Treatment Director Administration.

2 Primary function is UTILIZATION management, conducting UTILIZATION review and granting and denying authorizations for all Levels of Care (LOCs) and services as part of the Texas Department of State Health Services UTILIZATION Management (UM) Guidelines Conducts perspective, concurrent, and retrospective reviews for authorization of LOCs/services for individuals Conducts reviews using clinical information submitted by providers, direct contact with providers, review of medical necessity records, and contact with the individual and family members when needed and appropriate Makes initial adverse determinations and all clinical overrides (CORP) and exceptions to the UM. Guidelines, in consultation with the UM physician when indicated Monitors service delivery and outcomes to ensure services are not over-utilized or under-utilized Reviews data to detect outliers and unusual patterns of UTILIZATION and recommends interventions to the UM Committee Informs individuals and providers relative to appropriate treatment alternatives and community resources Performs UTILIZATION Care Management for those individuals with special circumstances needing special authorization by a Mosaic representative Participates in provider training on the UM process, monitors provider adherence to UM Guidelines.

3 And provides consultation when needed Makes recommendations for program improvements Supervisor: Clinical Treatment Director Supervises: N/A. Work Hours: This is a full-time, minimum 40 hours per week position. Work hours set by the employee, with allowances for some weekend, holiday, and evening hours required Classification: Exempt Education & Experience RN, RN-APN, PA, Psychologist, LCSW, LPC, or LMFT licensed in Texas and found by Pathways to be fully qualified to perform all UM functions and has: At least five years' experience in direct care of individuals with a serious mental illness including experience in an acute care setting;. At least five years' experience participating as a member of a treatment team that develops and monitors treatment plans for individuals with chronic and serious mental illness.

4 Documented training within the past three years in psychopharmacology, medical/psychiatric co-morbidity and complications of serious mental illness;. At least one year of experience supervising behavioral health providers; and demonstrated competence in performing UM and review activities. Knowledge, Skills, and Abilities Ability to support the agency's culture, growth, and success through communication, accountability, and positivity Ability to be clear headed and decisive based on the scope of the position Ability to work efficiently and effectively both individually and as part of a team Ability to appropriately accept feedback through the supervision process - thus displaying the willingness to learn, grow, and improve Competent in using Microsoft Word, Excel, the Internet.

5 And other software applications Effective oral/written communication and organizational skills Ability to effectively work as a part of a professional team Additional Requirements Proof of valid Texas Driver's License (Type C). Access to reliable transportation Copy of official state driving record Three (3) employment references Cleared criminal background check and signed statement regarding felony indictments/convictions Clear TB test results (current within 12 months prior to employment). Working cellular telephone at all times for on-call and after-hours availability DISCLOSURE STATEMENT. The above statements reflect the general details considered necessary to decide the essential functions of the job identified and shall not be construed as a detailed description of all work requirements that may be inherent in the job.

6 I HAVE READ THE ABOVE job description AND UNDERSTAND THE REQUIREMENTS OF THE JOB. UTILIZATION MANAGER Printed Name UTILIZATION MANAGER Signature Date Clinical Treatment Director Signature Dat