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Utilization Review Specialist
2 months ago
NeuroPsychiatric Hospitals is a leading healthcare provider with a unique approach to patient care. Our hospitals offer a comprehensive range of services, including neuropsychiatric and complex medical care, to patients with diverse needs.
Job SummaryWe are seeking a highly skilled Utilization Review Coordinator to join our team. As a key member of our care management team, you will be responsible for coordinating patient services across the continuum of care, promoting effective utilization, and monitoring health resources.
Responsibilities- Initial Precertification: Collaborate with payors to obtain precertification for patients, ensuring timely and efficient access to care.
- Concurrent Clinical Review: Conduct regular reviews with payors to ensure that patients receive necessary care and services.
- Document Management: Accurately document patient information and care plans in our electronic system, ensuring seamless communication among healthcare teams.
- Admission Audit: Conduct thorough audits of patient admissions to ensure compliance with hospital policies and regulatory requirements.
- Certification and Compliance: Ensure that all necessary certifications, such as CONs/RONs and CMS certifications, are completed by providers.
- Communication and Collaboration: Foster strong relationships with internal and external stakeholders, including patients, families, and healthcare teams.
- Professional Development: Stay up-to-date with industry trends and developments, attending relevant seminars and conferences to enhance your skills and knowledge.
- Confidentiality and Compliance: Maintain the confidentiality and integrity of patient information, adhering to all applicable laws and regulations.
- Appeals and Reconsiderations: Assist with appeals and reconsiderations, arranging peer-to-peer reviews and reporting outcomes to the VP of Care Management.
- Education and Training: Provide education and training to nursing staff, leadership teams, and providers on documentation and care management best practices.
- Business Office Collaboration: Work closely with the business office to resolve appeals, denials, and retrospective reviews.
- Education: Bachelor's or Master's degree in behavioral health or a related field, or a Registered Nurse (RN) degree.
- Licensure: QMA, CMA, CCM, ACM, or MA licensure (preferred).
- Skills: Strong knowledge of medications, exceptional time management, data entry, and communication skills, with a focus on detail-oriented work.
