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Clinical Utilization Manager

2 months ago

San Antonio, Texas, United States San Antonio Behavioral Health Full time
Job Summary

San Antonio Behavioral Health is seeking a highly skilled Utilization Review Coordinator to join our team. As a key member of our clinical operations team, you will play a critical role in ensuring the effective and efficient use of hospital services.

Key Responsibilities
  • Conduct Utilization Reviews: Conduct thorough reviews of patient charts and records to determine the appropriateness of care and treatment.
  • Monitor Patient Charts: Continuously monitor patient charts and records to evaluate care concurrent with patients' treatment.
  • Review Treatment Plans: Review treatment plans and status of approvals from insurers to ensure compliance with hospital policies and procedures.
  • Collaborate with Staff: Collaborate with registered nurse case managers, outcome managers, and other staff members to ensure that all hospitalized patients have the correct admission status.
  • Identify Opportunities for Improvement: Identify opportunities for process and system improvement and initiate and lead performance initiatives as indicated.
  • Facilitate Resolution of System Process Problems: Identify and facilitate resolution of system process problems impeding UM functions.
  • Validate Authorization Requests: Validate authorization requests are complete or requests additional data as necessary.
  • Perform Concurrent Reviews: Perform concurrent reviews for patients to ensure that extended stays are appropriately documented in patient's medical records.
  • Respond to Notices of Potential Denials: Respond to notices of potential denials and facilitate Physician to Physician appeals when appropriate.
  • Track Denial Information: Track denial information for reporting to Quarterly UR Committee.
  • Maintain Liaison with Social Services: Maintain liaison with the Social Services department to facilitate timely discharge planning.
  • Enter Complete and Accurate Documentation: Enter complete and accurate documentation into the system describing all patient related admitting/registration activities.
  • Follow Regulatory Policies and Procedures: Follow all regulatory policies and procedures, privacy and security standards in accordance with government agencies including HIPAA requirements.
Requirements
  • Education and/or Licensure: High School Diploma or equivalent.
  • Experience: 1-2 years Admitting or Financial Counseling preferred.
  • Additional Requirements: None.
Knowledge, Skills, and Abilities
  • Basic PC Skills: Must have basic PC skills that include a combination of working in a Windows Operating System and Microsoft Outlook, Word, and Excel.
  • Knowledge of Governmental and Managed Care Payer Requirements: Has knowledge of governmental and managed care payer requirements.
  • Understanding of Data Elements Required to Generate a Clean Bill: Understands the data elements required to generate a clean bill.
  • Understanding of Confidentiality: Understands the importance of maintaining confidentiality; able to maintain confidentiality under HIPAA standards.
  • Excellent Customer Service and Interpersonal Communication Skills: Must have the ability to exercise a high degree of diplomacy and tact; excellent customer services and interpersonal communication skills; Cultural sensitivity and demonstrated ability to work with diverse people groups.
  • Well-Developed Verbal and Written Communication Skills: Well-developed verbal and written communication skills in English; Additional language abilities desirable.
  • Knowledge of Basic Math and Modern Office Procedures: Knowledge of basic math and modern office procedures.
  • Ability to Work Well Under Pressure: Ability to work well under pressure with minimal supervision.
  • Ability to Remain Seated for Long Periods of Time: Ability to remain seated at switchboard for long periods of time without significant discomfort or distress.
Physical Requirements/Environmental Conditions
  • Ability to Perform Repetitive Motions: Ability to perform repetitive motions with wrists, hands, and fingers.
  • Ability to Exert Up to 100 Pounds of Force: Individual must be able to exert up to 100 pounds of force occasionally and to be able to lift, carry, push, pull, or otherwise move objects.
  • Ability to Work in a Fast-Paced Environment: Must be able to work and concentrate amidst distractions such as noise, conversation, and foot traffic; ability to handle interruptions often and be able to move from one task to another.
Benefits
  • 401K Retirement Plan: 401K Retirement Plan.
  • Medical/Dental Insurance: Medical/Dental insurance.
  • Short-Term Disability: Short-Term Disability.
  • Healthcare Spending Account: Healthcare Spending Account.
  • Dependent Care Spending Account: Dependent Care Spending Account.
  • PTO Plan with Holiday Premium Pay: PTO Plan with Holiday Premium Pay.
  • Life Insurance: Life Insurance.