Description

　　Conducts utilization review on all assigned cases and ensures authorizations are completed timely with all dates of service reviewed.

　　Documents all contact with payers and outcomes of reviews to ensure compliance. Participate in department in-service/training programs.

　　Provides consultation and guidance regarding admissions and continued stay criteria for a variety of payors.

　　Reviews clinical documentation from denied stays against criteria to determine if documentation is adequate for requested treatment.

　　Maintains current knowledge of applicable regulations and regulatory update in the behavioral health field.

　　Responsible for abundant data entry.

　　Validates that the request for authorization is complete or requests additional data from requesting physician, if necessary.

　　Follow all regulatory policies and procedures, privacy and security standards in accordance with government agencies including HIPAA requirements.

　　Provides accurate and complete clinical information to payors based on synthesized documentation in the medical record.

　　Completes retrospective reviews on assigned cases when updated insurance information becomes available subsequent to admission or after discharge.

　　Communicates discharges timely to payors for all assigned cases.

　　Notifies attending physician, direct supervisor and unit staff of in-house denial decisions.

　　Collaborates with the treatment team regarding quality and completeness of documentation and serves as a resource for nursing and clinical staff on documentation requirements.

　　Communicates with the responsible staff when clinical documentation is unclear, incomplete, unprofessional, or not relevant to the Master Treatment Plan goals and/or fails to supports medical necessity criteria for continued stay at the current level of care.

　　Participates in routine weekly chart auditing as assigned to ensure ongoing compliance with regulatory requirements.

　　Discusses utilization review decisions with patients and/or family members as appropriate.

　　Coordinates with clinical staff regarding progress of discharge planning for patients whose care has been denied.

　　Effectively manages time by scheduling concurrent telephonic reviews in advance when possible to efficiently manage caseload and work hours.

　　Attending clinical staff meetings to obtain clinical information pertinent to clinical reviews.

　　Additional Duties and Responsibilities

　　· Other duties as requested or assigned

　　Qualifications

　　Education

　　Required

　　Bachelors or better in Nursing/HealthcareExperience

　　Preferred

　　Personal and professional track record that demonstrates a commitment to quality in health care.

　　Proficiency in medical management software, medical appeals, and case management.

　　1-3 year: Utilization management experience.

　　Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

　　The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)