Utilization Review Clinician

Job Summary

Under the direction of the UTILIZATION REVIEW MANAGER, the Utilization Review (UR) Clinician will maximize covered/authorized inpatient days through coordination of care impacting length of stay, patient medical necessity, and appropriate discharge. The UR Clinician will be responsible for understanding, administering, and compliance for ALL Payer Inpatient Psychiatric Criteria including CMS Conditions of Participation, all GBH policies and procedures.

Position Qualifications

• Current, valid, and active BSN, LPN or LSW.
• Prior hospital case management or relevant experience preferred.
• Current BLS certification required through the American Heart Association or completion of Generations Behavioral Health's BLS course upon hiring

Responsibilities

• Thorough knowledge of medical necessity criteria for Medicare, Medicaid, HMO and private insurance payers related to Inpatient Psychiatric services.
• Use of standardized clinical templates, use of payer portals, and live reviews.
• Accurately obtain third party prior authorizations via payer portals, fax, or verbal communication, Continued Stay Reviews/pre-authorization extensions, and/or retro-active authorizations.
• Prepare and coordinate with Clinical staff regarding Peer-to-Peer appeals and 1st Level appeals.
• Participate in daily meetings and huddles in person, via telephone, or video conference to provide communication regarding covered days, upcoming authorization extensions, denials and provider plans for a timely discharge.
• Utilization Electronic Medical Record (EMR) and Practice Management (PM) software.
• Execute various hard or electronic paperwork, information files processing, fax documents, mail and other daily administrative tasks.
• Develop and maintain positive relationships with third party Prior Authorization staff.
• Ability to identify and resolve problems effectively and efficiently.
• Maintain an efficient, organized work environment.
• Effectively manage difficult customer situations; responds to requests for service and assistance.
• Maintain current knowledge of emergencies and disaster procedures of the facility.
• Participate in hospital-wide safety program identifying risks to patient safety and reducing healthcare errors.
• Ability to carry out essential functions of this position with or without reasonable accommodation.
• Perform other duties as assigned.

Working Conditions

Work occurs in a fast-paced psychiatric inpatient setting with patients who may display unpredictable or aggressive behaviors and must use de-escalation skills and follow safety protocols. The role requires frequent standing, walking, sitting, occasional lifting or assisting patients and the ability to respond quickly to emergencies while performing clinical tasks.

Job Details

• Full time
• 8-hour shifts
• Pay is based on experience
• Our Electronic Medical Record system is WellSky

EEO Statement

We are an Equal Opportunity Employer and do not discriminate based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, military service, political affiliation, genetic information or other non-merit-based factors.

Applicants requiring accommodation(s) during the application and or hiring process, may contact us for assistance. Employment is at-will. Employment is contingent upon background checks, pre-employment substance testing and verification of work authorization.

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Work Location: In person