Utilization Review Specialist

4 weeks ago


Harlingen, Texas, United States Summit BHC Full time

About the Role:

The Utilization Review Specialist will be responsible for reviewing assigned admissions, continued stays, and discharge planning according to approved clinically valid criteria. This role will ensure that all utilization review activities are conducted in a timely and efficient manner, with a focus on improving the collection, reimbursement, and coordination of utilization review information.

Key Responsibilities:

  • Perform admission, concurrent, continued stay, and retrospective reviews using established hospital criteria.
  • Communicate effectively with insurance companies, health maintenance organizations, and other entities to obtain approval for initial or additional inpatient days.
  • Appeal denials, ensuring accuracy of information and effective coordination of correspondence.
  • Assist the admissions department with pre-certifications of care and perform pre and post admission benefit verification with managed care organizations.
  • Maintain accurate documentation and files related to utilization management.
  • Provide ongoing support and training for staff on documentation requirements, continued stay criteria, and medical necessity updates.
  • Communicate effectively with coworkers, program, and nursing staff regarding charting deficiencies and problems identified.
  • Coordinate information and findings with the business office to help recognize or resolve possible payment problems.
  • 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, discharges, and quality of services.
  • Conduct quality reviews for medical necessity and services provided, and facilitate peer review calls between facility and external organizations.
  • Act as liaison between managed care organizations and facility professional clinical staff.

Requirements:

  • 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.
  • Two or more years of direct clinical experience in a psychiatric or mental health setting.
  • Current licensure as an LPN or RN or current clinical professional license or certification, as required, within the state where the facility provides services.

About Palms Behavioral Health:

Palms Behavioral Health offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications.



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