County of Alameda

Clinical Review Specialist (#6515)

Bargaining Unit: SEIU 1021 - Social Workers (005)
$47.53-$56.03 Hourly / $3,564.75-$4,202.25 BiWeekly /
$7,723.63-$9,104.88 Monthly / $92,683.50-$109,258.50 Yearly


DESCRIPTION
Under general direction, to provide behavioral care services by telephone, face-to-face, and/or record review for referral, treatment, and/or payment authorization and service integration; to gather and analyze case history data and treatment plans; to make treatment recommendations and to assess quality of care; to record all findings and maintain review records; and to do related work as required. Clinical Review Specialist positions are located in the Department of Behavioral Health Care Services ACCESS Program, Authorization Services and Quality Assurance. These positions provide a variety of clinical services including screenings and referrals, face to face assessments, review of medical necessity for authorization of services, utilization review, assessment of quality of care, and provider consultation.


DISTINGUISHING FEATURES

This is a journey level class, requiring a licensed professional, fully trained and professionally skilled upon entrance into the class. This position reports to a licensed clinical manager. Direct supervisory review and guidance is provided only in selected cases. Clinical Review Specialists provide behavioral care clinical assessment, clinical analysis, referral for treatment, treatment review, and provider consultation involving considerable latitude and independence of judgment. Incumbents in this class may lead and consult with other staff on clinical issues but do not have formal supervisory responsibility.

The class is distinguished from Behavioral Health Clinician II, Clinical Psychologist and Clinical Nurse II positions in that incumbents usually perform tasks using indirect information but may use direct interactions to provide behavioral health screenings and referrals, level of care assessments, or clinical direction to other licensed professionals and a large network of independent practitioners and organizations. This direction may include payment authorization, resource utilization management, quality improvement, quality assurance and coordination of multiple funding sources to support treatment requests.

EXAMPLES OF DUTIES

NOTE: The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Each individual in the classification does not necessarily perform all duties listed.

ACCESS PROGRAM

1. Provides county-wide telephone screening, evaluation, information and referral for mental health and substance use treatment services to beneficiaries of the Alameda County Behavioral Health Plans and the general public.

2. Provides in person clinical assessments to determine medical necessity and level of care need when additional information is needed following telephone screenings.

3. Evaluates clinical needs based on knowledge of developmental and age-related issues; assesses for level of care; authorizes treatment; and maintains records.

4. Provides consultation concerning medical necessity and utilization of system resources.

5. Provides telephone crisis intervention services, including arranging for emergency services when needed.

6. Gathers and analyzes clinical information, makes complex decisions about responsibility for payment, provides service integration and review of treatment options for all age groups, involving considerable latitude and independence of judgment.

AUTHORIZATION SERVICES

1. Provides daily case consultation and review to determine medically necessary treatment and appropriate utilization of system resources for both inpatient and outpatient mental health services and residential AOD services.

2. Consistently assesses level of care, treatment and disposition plans based on cultural, developmental and age-related parameters; assures in each medical necessity review that adequate documentation exists to substantiate provision of services and payment authorization.

3. Obtains information and documentation required to conduct pre-service, admission and continued stay hospital reviews, including determination of aftercare planning and placement efforts.

4. As necessary, visits provider sites to obtain information and conduct reviews.

5. Develops and records clinical information, utilization case management interventions, and payment authorization decisions using computer information systems to obtain and record information.

6. Makes decisions concerning reimbursement and use of county funds in order to balance regulatory requirements and utilization of scarce resources.

7. When assigned, conducts studies as directed, develops procedures, monitors, evaluates and reports within established time parameters.

8. Provides consultation to providers upon request to assist in the provision of crisis intervention services as well as non-urgent services. Utilizes consultation with physicians, peers, patient services and support staff to assist in authorization determinations.

QUALITY ASSURANCE:

1. Interprets, explains and applies complex regulations, policies and procedures in relation to the quality of patient care and the documentation of care.

2. Monitors compliance with regulations including but not limited to: documentation, chart reviews, utilization review, HIPAA, grievance tracking and reporting, change of provider requests, and site certifications.

3. Makes treatment recommendations and assesses quality of care.

4. Responds to provider inquiries regarding documentation, claiming, staffing, and other regulatory issues.

5. Authors and/or modifies quality assurance documents and manuals.

6. Manages audits, audit preparation and other efforts requiring interdepartmental coordination.

7. Conducts investigations related to grievances and/or complaints filed by individuals, community partners, or other parties.

8. Develops and delivers provider training and provides technical assistance as needed.


MINIMUM QUALIFICATIONS
Education:

Possession of a Master’s Degree from an accredited college or university in Social Work, Marriage and Family Therapy, Psychiatric Nursing, with an emphasis in Clinical Social Work, or equivalent degree which meets requirements set by the California Board of Behavioral Sciences;

OR

A Ph.D. in clinical, counseling, or educational psychology from an accredited college or university.

NOTE: Completion of an accredited registered nursing program, including three years post licensed nursing experience may be substituted for a Master’s degree in nursing.

AND

Experience:

The equivalent of three years of full-time, paid post-license experience in direct behavioral health care that includes treatment and disposition planning and/or the clinical review of these direct mental health and substance use disorder services.

License/Registration:

Possession of a valid clinical license from the applicable licensing authority: California Board of Behavioral Sciences, California Board of Psychology, or California Board of Registered Nursing.

Possession of a valid California Motor Vehicle Operator’s license. Applicants must possess such license prior to appointment to such positions.

Special Requirement:

In compliance with the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), employees in this classification are required to possess a National Provider Identifier (NPI) number prior to their first day on the job.

NOTE: The Civil Service Commission may modify the above Minimum Qualifications in the announcement of an examination.


KNOWLEDGE AND SKILLS
NOTE: The level and scope of the following knowledge’s and abilities are related to duties listed under the “Examples of Duties” section of this specification.

Knowledge of:

• Social and behavioral aspects of mental, emotional, substance use disorder (SUD)-related disturbances and their characteristics.
• Principles and practices of direct client service delivery.
• Scope, activities and functions of the various behavioral health facilities and public and private community agencies providing services to mental health and substance use disorder clients.
• Policies, procedures, and systems related to Behavioral Health Care Services, legal and regulatory requirements and limitations.
• Applicable federal, state and local laws, rules and regulations.
• Computer applications related to the work.

Ability to:

• Evaluate cases and perform advanced differential diagnosis of a mental disorder.
• Evaluate cases and perform advanced clinical risk assessment.
• Communicate effectively and document the biopsychosocial basis for triage, referral and authorization decisions.
• Communicate effectively selection factors related to a broad range of behavioral health care intervention modalities.
• Organize and prioritize work, and meet critical deadlines.
• Maintain accurate records and files.
• Input and/or access data via system-wide network computers and personal computers.
• Prepare clear, accurate and effective reports, correspondence and other written materials.
• Interpret, explain and apply complex regulations, policies and procedures.
• Effectively utilize community resources in the care of individuals with mental or substance use disorders.
• Establish and maintain effective working relationships with those contacted in the course of work.

CLASS SPEC HISTORY
RT:pf
8/28/00
Newspecs/ 6515.doc
CSC Date: 12/20/00
TE:sw Revised 10/13/05
CSC Date: 12/21/2005
SG:po Revised 7/16/09
CSC Date: 8/12/09
RY:cs Revised 5/29/13
CSC Date: 6/26/13
SP:cs Revised 1/21/15
CSC Date: 2/18/15

BENEFITS

Alameda County offers a comprehensive and competitive benefits package that affords wide-ranging health care options to meet the different needs of a diverse workforce and their families. We also sponsor many different employee discount, fitness and health screening programs focused on overall well being.  These benefits include but are not limited to*:

For your Health & Well-Being

  • Medical – HMO & PPO Plans
  • Dental – HMO & PPO Plans
  • Vision or Vision Reimbursement
  • Share the Savings
  • Basic Life Insurance 
  • Supplemental Life Insurance (with optional dependent coverage for eligible employees) 
  • County Allowance Credit
  • Flexible Spending Accounts - Health FSA, Dependent Care and Adoption Assistance
  • Short-Term Disability Insurance
  • Long-Term Disability Insurance
  • Voluntary Benefits - Accident Insurance, Critical Illness, Hospital Indemnity and Legal Services
  • Employee Assistance Program

For your Financial Future

  • Retirement Plan - (Defined Benefit Pension Plan)
  • Deferred Compensation Plan (457 Plan or Roth Plan)

For your Work/Life Balance

  • 11 paid holidays
  • Floating Holidays
  • Vacation and sick leave accrual
  • Vacation purchase program
  • Catastrophic Sick Leave
  • Employee Mortgage Loan Program
  • Group Auto/Home Insurance
  • Pet Insurance
  • Commuter Benefits Program
  • Guaranteed Ride Home
  • Employee Wellness Program (e.g. At Work Fitness, Incentive Based Programs, Gym Membership Discounts)
  • Employee Discount Program (e.g. theme parks, cell phone, etc.)
  • Child Care Resources
  • 1st United Services Credit Union 

*Eligibility is determined by Alameda County and offerings may vary by collective bargaining agreement.  This provides a brief summary of the benefits offered and can be subject to change.