Provides accurate and complete clinical information to payors based on synthesized documentation in the medical record.
Conducts utilization review on all assigned cases and ensures authorizations are completed timely with all dates of service reviewed.
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.
Collaborates and consults with Director of Utilization Review and Business Office Director on retrospective reviews, denials and appeals to maximize efforts to obtain authorization and overturn of adverse determinations.
Communicates denials to Director of Utilization Review and Business Office Director to ensure entry on the Denial Tracking Log.
Completes HMS entry in real time to include authorization numbers in Patient Maintenance.
Completes HMS entry in real time in the Utilization Review module with details of authorization/denial determinations
dates of service authorized/denied
payor contact, and
Notifies attending physician, Director of Clinical Services and unit staff of in-house denial decisions.
Attends unit rounds daily and treatment team meetings for assigned patients.
Serves as a co-facilitator for rounds by being prepared to discuss authorization status, anticipated third party review challenges and/or requirements for authorization.
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, 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.
Coordinates and schedules peer reviews on assigned cases and follows through with medical staff and payors to ensure peer reviews and expedited appeals are completed timely, and documented in HMS with outcomes communicated to Director of Utilization Review, Business Office Director, CFO and CEO.
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.
Ensures coverage for any planned time away from the facility.
Communicates any incomplete work or failure to manage responsibilities timely to supervisor so responsibilities can be reassigned to prevent penalties or negative outcomes.
Work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee may occasionally be exposed to fumes or airborne particles. The noise level in the work environment may be moderate to high. The work environment may include chemicals used for cleaning, and have dust, mist and stream generated in housekeeping tasks. Smoke-free work environment.
Must provide documentation of a current physical examination and tuberculosis test prior to beginning employment; and TB test annually thereafter.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Knowledge, Skills, and Experiences Required:
Education: Master's prepared clinician with an independent practice scope license or Registered Nurse with a minimum of two years psychiatric experience.
License: Appropriate state license required.
Experience: Must have at least one year experience in a psychiatric setting. Prior utilization review experience preferred. Demonstrated excellent verbal and written communication skills. Ability to manage caseload independently with minimal supervision.