Lower Eastside Service Center New York , NY 10007
Posted 4 weeks ago
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Job Type
Full-time
Description
MAJOR DUTIES:
In concert with the agency's mission and goal of sustaining high quality care/service delivery to persons served, the Utilization Manager works to assist CASAC Counselors and supervisory staff as needed with assuring compliance with external and internal utilization review/quality and appropriateness requirements
The Utilization Manager is responsible for the day to day functions of collaborative communication with external case managers at referring provider facilities and/or managed care organizations (MCO) for data collection, interpretation and certification/recertification from third party payers at pre-admission through discharge, ongoing medical necessity reviews and interdisciplinary team support with respect to MCO requisites
In addition, this position is responsible for having a thorough understanding of patient treatment plans through participative discussions with the care plan (interdisciplinary) team, identifying and referring requests for services to the Medical Director when guidelines are not met and reviewing residential services requiring MCO approval
Obtaining the required pre-authorization/certification of specified services from the MCO and communicating end of benefit status and/or reimbursement changes to Finance and others as deemed necessary
Conducting ongoing medical necessity reviews, which may be pre-service, concurrent and/or retrospective in nature, by evaluating clinical data and submitting appropriate documentation to update the patient/resident's status to the MCO as scheduled
Acting as a liaison between the residential program and the MCO to better facilitate the reimbursement process
Referring MCO denials and non-covered medical services to the directors for appeal determination and next steps
Conducts timely and complete quality and appropriateness reviews on a representative sample of treatment records for residential service sites
Provides Supervisory support to CASAC Counselors and Peer Workers as needed with supervisory guidance from Management/Leadership Team
Monitors and evaluates ongoing audit for chart
Provides direct care services to clients as needed
Assists with the maintenance of the agency's OASAS reviews and CARF accreditation for the program, i.e., standards review and conformance auditing
Performs other duties as assigned
SCHEDULE: Monday-Friday 9AM-5PM
RATE: $62,500 - $65,500 / year (dependent on experience)
LOCATION: NY, NY 10002
We offer excellent benefits including:
Generous time off that includes 4 weeks of vacation
Medical, Dental, and Vision Insurance
Discounted Commuter benefits
Life insurance & Long term disability
Eligible for Federal Student Loan Repayment Program
Training and other additional voluntary benefits
To join our diverse team, please include salary requirements with your resume/application submission. Please visit us at www.lesc.org EEO Minorities/Women/Disabled/Vet
Requirements
QUALIFICATIONS - EDUCATION AND PROFESSIONAL EXPERIENCE:
Minimum of 2 years of case management and/or utilization review experience
Strong problem-solving and advanced analytical skills necessary to read, understand, interpret and analyze statistical data
Excellent oral, written, organizational and interpersonal communication skills
Ability to communicate effectively with senior leadership as well as other clinical/non clinical directors, managers, staff, consultants and MCOs
Demonstrated ability to effectively collaborate with peers and senior leadership on project assignments and group presentations
OASAS CASAC Certification (with Bachelor's Degree)
Other QHP credential such as LMSW, LMHC, LMSW-LP, or MHC-LP (with Master's Degree)
Master's Degree in Social Work or related field;
In depth knowledge on HIPAA, OASAS, and 42 CFR regulations
Working knowledge of quality assurance and utilization review systems
Computer literacy including proficiency in Microsoft Office Suite and HER
Experience working directly with people from diverse racial, ethnic, and socioeconomic backgrounds
Competency in written, interpersonal, verbal, and computational skills to present and document records in accordance with program standards
Ability to work independently
Salary Description
$62,500 - $65,500 / year (dependent on experience)
Lower Eastside Service Center