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Utilization Management Specialist

2 months ago

Smyrna, Georgia, United States Ridgeview Institute Smyrna Full time
Position Overview

The Outpatient Utilization Management Coordinator plays a pivotal role in ensuring the effective management of patient care within the healthcare system. This position involves collaborating with external case managers and managed care organizations to secure necessary insurance certifications and recertifications throughout the patient's treatment journey.

Key Responsibilities

The essential duties of the Outpatient Utilization Management Coordinator include but are not limited to:

  • Engaging with the treatment team to clarify insurance requirements for continued care and discharge planning.
  • Advocating for patient access to necessary services during treatment discussions and through direct communication with physicians.
  • Conducting daily concurrent reviews and obtaining initial preauthorization for new patients entering PHP/IOP programs.
  • Chairs treatment team meetings and leads continued stay reviews as required.
Case Management Duties

The following are critical case management functions:
  1. Evaluate treatment plans and advocate for additional services as needed.
  2. Promote efficient resource utilization for patients.
  3. Ensure the protection of patient rights.
  4. Maintain ongoing communication with the attending physician, program manager, nurse manager, and team members.
  5. Collaborate with the treatment team on issues related to continued care and discharge planning.
  6. Ensure appropriate placement of patients in suitable care levels and programs.
  7. Facilitate smooth transitions during patient transfers or discharges.
  8. Document all case management activities accurately.
  9. Track insurance reviews and ensure timely completion.
  10. Prepare statistical reports and document significant findings.
Qualifications

Education: A Bachelor's or Master's degree in social work, mental health, nursing, or a related field is required.

Experience: A minimum of two years of relevant experience in a healthcare setting or managed care organization, focusing on patient assessment, treatment planning, and utilization management is preferred.

Licensure: A valid driver's license is required.

Additional Requirements: Successful completion of CPR/First Aid certification and CPI training within 90 days of employment. Flexibility in working hours may be necessary.

Knowledge, Skills, and Abilities:
  • Understanding of case management techniques.
  • Familiarity with patient assessment and treatment planning.
  • Knowledge of external review organizations (managed care, Medicare, Medicaid, etc.).
  • Strong leadership and negotiation skills.
  • Excellent customer relations and communication skills.
  • Ability to manage conflicting situations effectively.
  • Attention to detail in a fast-paced environment.
Compensation and Benefits

This is a full-time, non-exempt position with a competitive compensation range. The organization offers a comprehensive benefits package, including health insurance, retirement plans, and paid time off, among other perks.

About Ridgeview Institute Smyrna

Ridgeview Institute Smyrna is a leading healthcare provider dedicated to excellence in mental health and addiction treatment. The organization values a diverse and inclusive workforce, ensuring equal employment opportunities for all applicants and employees.