KATANGIAN NG PAMAMARAAN NG UTILIZATION
Carelon places a high value on the selection, training and performance evaluation of clinical staff performing utilization management services. All staff involved in utilization management activities possess terminal degrees and licensure in their field. Carelon Physician Peer Advisors and Medical Directors are experienced, senior level clinicians, many of whom remain active in private practice. They are board certified in their specialty areas and are required to maintain a current knowledge of behavioral health research findings and nationally recognized practice guidelines. Licensed Clinical Psychologists provide peer reviews for psychological testing and outpatient treatment.
The clinical Utilization Management staff is multidisciplinary and is able to manage care in all general psychiatric, psychiatric subspecialty and substance abuse areas. Carelon requires that all of our Service Managers/CAFS Coordinators and reviewers be fully licensed mental health professionals with a minimum of three years prior clinical experience in a mental health/substance abuse setting providing direct patient care. First-level review staff may be nurses (RN or MSN) or masters, doctoral prepared licensed behavioral health clinicians. These reviewers complete all types of reviews, including referral, precertification, concurrent review, discharge planning and complex care management. Ang lahat ng mga provider ay kinakailangang sumunod sa proseso ng pagsusuri.