UR Specialist

The Utilization Specialist is responsible for reviewing of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria which meets the daily deadlines to obtain authorizations and complete other pertinent processes. Coordinates, performs, and monitors all utilization review/management activities of the hospital to continuously improve the collection, reimbursement, coordination, and presentation of utilization review information; Educates hospital staff about requirements and trends.
Performs admission, concurrent, continued stay, and retrospective reviews using the established hospital criteria. Communicates effectively with insurance companies, health maintenance organization (HMOs) and other similar entities for approval of initial or additional days for treatment. need in a logical, concise manner using technical language that accurately describes client’s condition and need for hospitalization.
* Assists the admissions department with pre-certifications of care. Performs pre and post admission benefit verification with managed care organizations.
* Provides ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.
* Communicates effectively with co-workers, program, and nursing staff regarding charting deficiencies and problems/issues identified. Coordinates information and findings with the business office to help recognize or resolve possible payment problems.
* Monitors client length of stay and extensions and informs clinical and medical staff on issues that may impact length of stay. Investigates short term length of stays and endeavor to create alternate financial planning which would offer the client extended days of treatment. Participates in discharge planning as required.
* Gathers and develops statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
* Conducts quality reviews for medical necessity and services provided. Facilitates peer review calls between facility and external organizations. Acts as liaison between managed care organizations and the facility professional clinical staff.
* Assists with any problems encountered during on-site or telephone reviews by the third-party payers or review organization, when necessary.
* Graduation from an approved/accredited school of nursing or a bachelor's degree in social work, behavioral or mental health, or other related health field preferred.
* Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.
Job Type: Full-time