Utilization Review Specialist
3 weeks ago
ESSENTIAL FUNCTIONS:
* Act as liaison between managed care organizations and the facility professional clinical staff.
* Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
* Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
* Gather and develop 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.
* Conduct quality reviews for medical necessity and services provided.
* Facilitate peer review calls between facility and external organizations.
* Initiate and complete the formal appeal process for denied admissions or continued stay.
* Assist the admissions department with pre-certifications of care.
* Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.
OTHER FUNCTIONS:
* Perform other functions and tasks as assigned.
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:
* Associate's degree in nursing (LPN or RN) required. Bachelor's or Master's degree in social work, behavioral or mental health, nursing or other related health field preferred.
* Two or more years' experience with the population of the facility and previous experience in utilization management preferred.
LICENSES/DESIGNATIONS/CERTIFICATIONS:
* Current licensure as an LPN or RN within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.
* CPR and de-escalation and restraint certification required (training available upon hire and offered by the facility.
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