Psychologist Peer Reviewer (Remote NC)

LOCATION: Remote - this is a home based, virtual position. This person must live in North Carolina or within 40 miles of the North Carolina border.

GENERAL STATEMENT OF JOB

The Psychologist Peer Reviewer is part of the Utilization Management Team who conducts Peer Reviews and fulfills multiple other functions involved with service reviews and appeals, ensuring that Vaya Health (Vaya) adheres to regulatory due process requirements and to Vaya policies and procedures. The Peer Reviewer conducts Initial Peer Reviews of authorization requests for behavioral health, intellectual/developmental disability (I/DD), and traumatic brain injury (TBI) services that Utilization Management Clinicians cannot approve for medical necessity reasons and conducts Reconsideration and First Level Appeal reviews when initial denial decisions are appealed. The individual also participates in planning and conducting Mediations, Office of Administrative Hearing appeals of Medicaid service denials, and State Level appeals of state-funded service denials. The individual provides support to the Member Appeals Team in their generation of accurate and timely correspondence to members, legally responsible persons, and providers explaining denial and appeal decisions. The person in this role provides information to Vaya staff, consumers, guardians, providers and others regarding the denial and appeals processes in general and regarding the status of specific cases as needed. Finally, the Peer Reviewer works with other staff on the Member Appeals Team and with other Vaya departments to report denial and appeal outcomes and processes, and to ensure adherence to quality standards.

ESSENTIAL JOB FUNCTIONS

Conduct Clinical Peer Reviews:

• Conduct Initial Peer Reviews of non-physician-directed services when Utilization Review Clinicians are unable to authorize requested services due to medical necessity concerns
• Conduct first level appeal Peer Reviews of Medicaid and State-Funded service denials for which the initial Peer Reviewer was a Psychologist and not the contracted employee's supervisor.
• The Psychologist Peer Reviewer must be located in a state or territory of the United States when conducting a Clinical Peer Review.

Facilitate Denial and Appeal Processes:

• Assist other Member Appeals Team staff and UM Clinicians implementing denial and appeal processes consistent with regulatory requirements and Vaya policies and procedures.
• Assist other Member Appeals Team staff with maintaining team procedures, templates, and other documentation needed for completion of Member Appeals' responsibilities and tasks.
• Provide consultation to members, guardians, providers and Vaya staff, as requested, regarding the First Level Appeal processes.
• Review Clinical Peer Reviews completed by others to ensure that reviews were conducted appropriately; address any deficiencies identified.
• Review Notification Letters to ensure accuracy of information.
• Assist with generation of principal reasons from denial and appeal decisions for inclusion in appeal correspondence.
• Participate in review and planning for cases in which second level (OAH) appeals are requested.
• As requested, represent Vaya in Mediation Hearings

Clinical Consultation and Support:

• Provide clinical consultation and support to other Vaya teams and departments as requested on topics such as I/DD conditions and services, Critical Incident Training for law enforcement personnel, etc.
• As requested, participate in reviewing and responding to grievances regarding Vaya's denial and appeal processes.
• Participate in the identification and implementation of quality improvement activities for denial and appeal processes.

Committee Participation and Meeting Attendance:

• Attend scheduled committee meetings. Provide adequate notice if unable to attend and request proxy attendance if a proxy is assigned
• Prepare presentation materials as needed for assigned committees.
• Provide consultation in areas of expert competence as needed.
• Provide trainings to other Vaya teams, providers, or community entities.
• Participate in internal ad hoc workgroups as assigned. Various different duties related to the needs of the incumbent's assigned department

KNOWLEDGE, SKILLS, & ABILITIES

• Participate in process to evaluate medical necessity and clinical appropriateness of services requested and make determinations on intensity and level of care requests
• A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance. This will require exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts. Problem solving, negotiation, arbitration and conflict resolution skills are essential to balance the needs of both internal and external customers.
• Strong writing and editing skills are required.
• Knowledge and understanding of state and federal managed care and due process regulations is required.
• Mastery of utilization review principles to ensure continuity of care and clinical evaluations as needed for appropriate provision of intensive, crisis services and other levels of care.
• Knowledge of prior authorization review, continued stay and discharge reviews for MH/SU services to ensure appropriate service intensity and level of care for consumer.
• Knowledge of documentation and clinical protocols for utilization purposes.
• Knowledge of linkage, authorization and level of care determinations, assisting providers with creative problem solving to suggest alternative approaches to care.
• Clinical knowledge of managed systems of mental health and substance use disorders. Knowledge of managed behavioral care practices and principles involved in Utilization Review.
• Ability to collaborate with providers and other agencies.
• Clinical knowledge of mental health, substance abuse and intellectual/developmental disability treatment as a basis for clinical reviews and decisions for authorization.
• Comprehensive knowledge of resources and the ability to use a personal workstation. Knowledge of database and data entry is essential.

QUALIFICATIONS & EDUCATION REQUIREMENTS

Doctoral degree in Psychology from a regionally accredited university or professional school of psychology is required. Clinical experience in behavioral health setting with 3 or more years experience in IDD and Autism Spectrum Disorder populations.

Licensure/Certification Required:

Current, unrestricted North Carolina licensure as a Psychologist (Psy.D, or PhD).

Preferred work experience:

Experience in Utilization Management in a managed care environment (as a clinician, employee, or peer reviewer).

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not

eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.