Utilization Review Specialist - Northlake Behavioral Health System
Mandeville, LA 70448
About the Job
Position Summary: Responsible for proactively monitoring the utilization of continuum services and optimize reimbursement for the system. Reviews clinical documentation on each patient and works directly with managed care or insurance companies/entities performing concurrent, live reviews with provided clinical documentation to get additional patient days authorized for payment as needed. Communicates with the inter-disciplinary team members to ensure optimal length of stay for patients depending on their continued medical necessity for treatment or care; reviews and provides feedback to the Medical Director, psychiatrists, DON and clinical leaders as to quality of documentation to support continued medical necessity
Essential Functions:
· Develops and maintains effective working relationship with all disciplines
· Advise treatment team when clinical criteria have been inadequately documented
· Obtains additional information from Medical, Nursing, and Social Services as needed to determine medical necessity for continued stay
· Manages workload in an effective manner
· Obtain daily clinical documentation to assess for accuracy and completeness
· Organizes information daily for each case to be presented to Third party payers for continued authorization.
· Conducts Precepts and / or concurrent reviews daily
· Files Appeals for denials as indicated
· Evaluates information in patient record for medical necessity of continued stay at current level of treatment
· Assimilates all clinical information into a concise, cogent product
· Completes all needed case reviews and needed follow up daily
· Completes all data entry of review results in the client information system daily
· Completes all data entry of review results in Approval /Denial Log daily
· Communicates effectively with managed care and referral sources.
· Maintains positive working and collaborative relationships with insurance and managed care providers.
· Communicates with OBH Staff as needed
· Inputs all data in system as needed
· Ensures all documents and clinicals are gathered and sent for OBH patients – as OBH Requests through email or Portal
· All other duties as assigned
Minimum Qualifications:
Education:Associate’s Degree or higher preferred in: Nursing, social work, psychology, health information management or other healthcare field is preferred, or related experience. May substitute Degree with High School Diploma with minimum of 4 years Psychiatric/Mental/Behavioral Health Experience.
Experience:Experience in a psychiatric setting, knowledge of health care service delivery systems, and third-party reimbursement preferred; knowledge of managed care environment.
Competency:N/A
Licensure/Certification:Professional clinical license issued by the appropriate licensing body in Louisiana; CPR certification and CPI certifications preferred as needed
HIPAA:Has access to and adds information to the Medical Record. May only access medical record of assigned patients