Utilization Manager
3 weeks ago
POSITION OVERVIEW:
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.
KEY ESSENTIAL FUNCTIONS:
- 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
- Conduct medical record reviews of all managed care patients within the first 24 to 72 hours (if admitted on a Friday after 5:00pm) then weekly as required to promote desired clinical and financial outcomes by, but not limited to:
- Meeting with all managed care residents/patients to better assist in the selection of appropriate provider resources and identification of quality and cost effective services throughout the continuum of care
- Acting as a resource to the interdisciplinary team in regard to MCO requirements for admission, continued stay and discharge planning
- Providing early identification of covered care and ensuring that claims are approved when the requirements are met
- Collaborate with clinicians to identify discharge needs and coordinates with Social Services in the creation and implementation of a discharge/transfer plan
- Coordinates post-discharge follow-up care with selected patients and community providers
- Maintains strong leadership skills to perform the multiple functions and a wide variety of tasks requiring independent judgment, ingenuity and initiative
- Interacts with executives, directors, key members of the residential team, physicians and their staff, third party payers, state and federal agencies, auditors and vendors
- Maintains a high degree of computer proficiency with MS Word and MS Excel which is critical for the analysis conducted using this technology
- Maintains all information in a manner such as to assure strict confidentiality and compliance with HIPPAA
- Maintains full knowledge and understanding of state and federal regulations as they pertain to resident assessment requirements
- Performs all other tasks including miscellaneous special projects as directed
REQUIREMENTS:
- Minimum of 2 years of case management and/or utilization review experience
- Associate degree required; bachelor's Degree preferred
- 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
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