PRN Utilization Review Specialist

Principal Functions:

Implement, coordinate and participate in a variety of admissions, utilization management, and ongoing review of clinical documentation in acute behavioral health setting. Determine if a patient’s insurance is appropriate and acceptable for admission to the hospital. Collaborates with clinical treatment team to determine continued stay appropriates. Collaborates with social services for discharge planning in accordance with outcomes of clinical reviews. Communicates efficiently with nursing staff and other members of the clinical team to ensure proper documentation in accordance with CMS standards and regulations. Manages and coordinates organization-wide efforts to ensure that performance management and quality improvement programs.

Position Duties:

Conduct utilization review and authorization procurement for acute care behavioral health services

Conduct concurrent reviews within designated timeframe

Uses electronic systems, payer websites, and telephone verification as needed for verification of insurance and ensure appropriate benefit levels in conjunction with the intake team

Completes insurance verification after hours and on weekends (minimum of 7 days per month - rotating on call basis)

Apply Behavioral Health Inpatient LOC criteria and other utilization review criteria, as outlined in health plan provider manuals, to patient authorizations and concurrent reviews, peer to peer reviews and appeals.

Reviews clinical documentation and interviews clinical staff to facilitate demonstration of clinical need

Work closely with clinical and administrative teams to facilitate the authorization lifecycle and communicate payer requirements.

Use sound judgment to determine appropriate documentation to support authorizations.

Solves complex problems and takes a new perspective on existing solutions in support of hospital’s goals

Participates in discharge planning in conjunction with treatment team to ensure appropriate benefit utilization

Perform reviews/ audits, analyze audit results and reports findings to promote and improve processes.

Participate in quality improvement activities and will ensure appropriate tracking/reporting of utilization data across the organization.

Coordinates with patients, families, referral sources, providers and key departments to promote an understanding of Prior Authorization and Insurance Verification requirements and processes

Reports over/under utilization and clinical criteria concerns to Director of Utilization Review

Increases the organizations capacity to evaluate and improve the effectiveness of their practices, partnerships, programs, use of resources, and the impact the systems’ improvements had on the organization.

Performs other duties and responsibilities as assigned.

Minimum Qualifications:

Education: Work generally requires a Bachelor's degree in Social Work, Behavioral Science or a related field. Active LPN or RN may be considered in lieu of Bachelor’s degree, depending upon experience.

Training: Work requires a minimum of two years of experience in patient/health care relations or a human services field (e.g. teaching, employee relations, public relations, counseling).

Skills: Utilization or case management in a behavioral health system either through managed care or healthcare provider highly desirable.

Experience in Utilization management or procurement of authorizations with either a psychiatric hospital, behavioral treatment facility, or as a case manager for and insurance company in behavioral health.

Previous experience with insurance benefit verification and familiarity with Managed Care entities, Medicaid, and Medicare required

Broad knowledge of clinical terminology, working understanding of psychiatric medications, psychiatric assessments and clinical terminology as it relates to patient presentation and mental status.

Ability to establish and maintain effective working relationships with providers, management, staff, and contacts outside the organization.

Ability to organize and prioritize work and manage multiple priorities.

Working Conditions:

• Ability to sit for long periods of time.
• Occasional bending, stooping and reaching required.
• Manual dexterity required to operate modern office equipment.
• Employee may be required to lift up to 50 pounds.
• Employee must have normal or correctible range of hearing and eyesight.
• Working conditions include fast-paced, demanding environment, constant communication with other manages and travel to practice sites.

Miscellaneous

Seeks guidance and remains knowledgeable of, and complies with, all applicable federal and state laws as well as regulations and hospital policies that apply to assigned duties.

Complies with hospital expectations regarding ethical behavior and standards of conduct.

Complies with federal and hospital requirements in the areas of protected health information and patient privacy.

Some duties may be reassigned and other duties may be assigned as required in the hospital's sole discretion.