Utilization Review Manager - SUD

Utilization Review Manager - SUD | Anabranch Recovery Center | Terre Haute, Indiana

About the Job:

The Utilization Management Manager is responsible for the overall management of the UM department by leading and facilitating review of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria. Directs and manages the day-to-day operations and supervision of staff to obtain coverage for clients, monitors the progress of all UR cases and insurance appeals, problem solves when necessary and mitigates all issues with utilization. Monitors utilization of services and optimizes reimbursement for the facility while maximizing use of the client’s provider benefits for their needs. This position is onsite at the facility and is not a remote position.

Roles and Responsibilities:

ESSENTIAL FUNCTIONS:

• Assigns all clients to Utilization Review staff and supervises staff to ensure staff are completing insurance verifications on time and compliant with regulatory standards and requirements.
• Ensures staff are competent to review medical records of clients for appropriateness of level of care at admission and at intervals determined by documentation in medical record and to communicate client insurance status and needs with all disciplines.
• Identifies and prioritizes issues of importance, including those priority issues as set for by leadership. Collaborates with department leaders and corporate leaders, as needed.
• Communicates instructions, expectations and timelines clearly and concisely.
• Leads a team of highly engaged members through hiring, orienting, performance assessment and management, motivating, training, scheduling, and coaching to meet department goals and ensure effective and efficient department operation.
• Maintains productivity levels that are aligned with client census, curtailing unnecessary overtime and/or excessive staff work hours.
• Manages staff scheduling and maintains an updated plan for contingency staffing.
• Maintains accountability expectations for self and staff in all areas of job performance.
• Engages staff in quality and safety basics to ensure sustained, measurable compliance.
• Identifies staff educational needs and ensures they are addressed with education programs that are attended by staff.
• Hold staff accountable for non-compliance and client safety concerns, as well as attendance, following policies, behavior, and adherence to code of conduct.
• Works closely with Admissions Department to ensure client information is accurate and pre-certification is complete. Reviews application for client admission and approves admission or refers case to utilization review committee for review and course of action when case fails to meet admission standards.
• Manages any discrepancies regarding stated benefit information and insurance verification, need for updated benefits or follow-up on a problem with a pre-certification from admissions.
• Appeals all denials ensuring accuracy of information and effective coordination of correspondence.
• Analyzes client records to determine appropriateness of admission, treatment, and length of stay to comply with government and insurance company reimbursement policies. Ensures charting deficiencies are minimized and corrected timely by responsible staff. Identifies and forwards charts for review based on outlying data to the Medical Director.
• Analyzes insurance, governmental and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of clients.
• Compares client’s medical records to established criteria and confers with medical, clinical, nursing, and other professional staff to determine appropriateness of treatment and length of stay. Communicates and coordinates information with business office to recognize and resolve potential payment issues.
• Conducts and oversees concurrent and retrospective reviews for all clients. Assists review committee in planning and holding mandated quality assurance reviews.
• Acts as a liaison between Medicaid reviewers and the staff completing required paperwork to facilitate the Utilization Review process.
• May be required to provide onsite coverage for other programs when needed, develops, and executes new programs according to market needs and may provide training, case consultation and Administrator On Call coverage during and after program hours as needed.
• May perform Leadership Rounds as assigned to include observation and immediate identification of environment of care, safety, and infection control concerns, as well as real time education of new facility processes.
  
  
  

ADDITIONAL RESPONSIBILITIES:

• Develops and implements program policies and procedures that guide the provision of services.
• Maintains regular and reliable attendance.
• Meets expectations as an exempt employee to work additional hours as required to meet facility needs and project deadlines.
• Maintains professionalism and confidentiality of facility employees and clients.
• Performs other duties as assigned.
  
  
  

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• High School Diploma or equivalent required. Graduation from an accredited school of nursing OR a Bachelor's degree in social work, behavioral or mental health, or other related health field preferred.
• Two or more year's clinical experience in a substance abuse setting required.
• Two or more years’ experience in medical/psychiatric utilization management required.
• Comprehensive understanding of the admission, concurrent, continued stay, and retrospective reviews using the established facility criteria.
• Ability to communicate professionally and effectively with multidisciplinary team members, managed care organizations and business office, providing needed information in a logical, concise manner using technical language that accurately describes client’s condition.
  
  
  

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• Current licensure as an LPN or RN or current clinical professional license or certification, as required, within the state where the facility provides services.
• CPR and de-escalation certification required (training available upon hire and offered by facility).
• First aid may be required based on state or facility requirements.
  
  
  

SUPERVISORY REQUIREMENTS:

Minimum of one year supervisory experience in clinical setting/utilization required.

Why Anabranch Recovery Center?Anabranch Recovery Center offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications. Qualified candidates should apply by submitting a resume. Anabranch Recovery Center is an EOE.

Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.