The Utilization Manager is responsible for management of all utilization review/case management activities for the facility’s inpatient, partial hospitalization, and outpatient programs. . Conducts concurrent reviews of all medical records to ensure criteria for admission and continued stay are met and documented, and to ensure timely discharge planning. Coordinates information between third party payers and medical/clinical staff members. Interacts with members of the medical/clinical team to provide a flow of communication and a medical record which documents and supports level and intensity of service rendered. All duties to be done in accordance with Joint Commission, Federal and State regulations, Oceans' Mission, policies and procedures and Performance Improvement Standards.
Conducts review of inpatient records as outlined in the Utilization Review/Case Management plan to:
Determine appropriateness and clinical necessity of admissions, continued stay, and, and discharge;
Determine timeliness of assessments and evaluations; i.e. H&Ps, psychiatric evaluation, CIA formulation, and discharge summaries; and
Identify any under-, over-, and/or inefficient use of services or resources.
Verifies that the pre-certification is completed within the designated time requirement as established by the payer – ensuring that the authorization identifier is entered in the electronic medical records UR Tracking module.
Facilitates the Quarterly UM Committee and reports findings to appropriate disciplines and/or committees; notifies appropriate staff members of any deficiencies noted so corrective actions can be taken in a timely manner.
Coordinates flow of communication between physicians/staff and third-party payers concerning reimbursement prerequisites; conducts concurrent reviews and follows through with documentation requests from third party payers; maintains abstract in the electronic medical record UR tracking module with updates provided to third party payers.
Actively participates in status meetings daily and weekly treatment team.
Manages clinical denials by:
Documents denial in the electronic medical record Denial Management module
Notifies physicians/staff/ of denial
initiates and completes appeals process for denials
Coordinates with the financial counselor notification of the denial to the patient follow-up with payer on appeal until resolution or exhausted all efforts.
Conducts special retrospective studies/audits when need is determined by UM Committee.
Actively participates in weekly UM Management meetings and monthly AR Review calls.
Performs other duties and projects as assigned.
Bachelor's degree in social services field required with RN or LPN license preferred. At least two years psychiatric/chemical dependency experience with good working psychiatric/medical knowledge.
Must have excellent assertive communication skills and leadership skills. Knowledge and in-depth understanding of CD/psych treatment and discharge planning process. Must have good writing and composition skills. Must have good understanding of regulatory and fiscal reimbursement and utilization review as a primary component of patient care. Must demonstrate strong patient advocacy skills. Must be able to organize and prioritize high volume workload. Must be able to analyze and utilize data and systems to provide individualized quality treatment in a cost-effective manner. Must be able to function with minimal supervision. Therapeutic Intervention De-escalation Education required. Must have ability to maintain overall good work attitude and interact cooperatively and professionally with other staff members and third party payers to achieve mutually beneficial outcome. Must possess basic competency in age/disability/cultural diversity needs of patients served and ability to relate to patients in a manner sensitive to those needs. Must successfully complete CPR certification and an Oceans approved behavioral health de-escalation program.
Subject to many interruptions. Occasional pressure due to multiple calls and inquiries. This position can be high paced and stressful; must be able to cope mentally and physically to atmosphere. Work requires spending approximately 90% or more of the time inside a building that offers protection from weather conditions but not necessarily from temperature changes.