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Behavioral Health Utilization Coordinator
2 months ago
We are seeking a highly skilled Clinical Utilization Review Specialist to join our team at Hospital for Behavioral Medicine. As a key member of our clinical team, you will play a critical role in ensuring that our patients receive the highest level of care and that our utilization review processes are efficient and effective.
Key Responsibilities- Case Management/Utilization Management
- Review treatment plans and advocate for additional services as indicated.
- Promote effective use of resources for patients.
- Ensure that patient rights are upheld.
- Maintain ongoing contact with the attending physician, program manager, nurse manager, and various members of the team.
- Collaborate with the treatment team regarding continued stay and discharge planning issues.
- Advocate that the patient is placed in the appropriate level of care and program.
- Interface with program staff to facilitate a smooth transition at the time of transfer or discharge.
- Maintain documentation related to case management activities.
- Assure tracking of insurance reviews, and that reviews are completed in a timely manner.
- Maintain statistical reports and prepare documentation of significant findings.
- Communicate insurance requirements to all levels of staff.
- Provide timely updates regarding patient status on log sheets that are prepared for daily meetings concerning admissions, reviews, and discharges.
- Update the denial log statistics on an ongoing basis (at least weekly), and initiate appeals through telephone or written communication within 7 to 10 days of denial.
- Consult with the business office and/or admission staff as needed to clarify data and ensure the insurance precertification process is complete.
- Provide clinical information to managed care companies, insurance companies, and other third-party reviewers to establish the length of stay or number of certified days.
- Coordinate with the insurance company doctor in appeals process and denials process.
- Review assessment information.
- Attend and chair and coordinate treatment team continued stay reviews, as indicated.
- Communicate with attending physician and program managers, and other providers of service, to assure continuity of care, efficiency, and effective transitions between levels of care.
- Provide feedback to the attending physician and treatment team members concerning continuing certification of days/services.
- Communicate with external reviewers and referral sources. Conduct external reviews and maintain documentation of interactions.
- Ensure that third-party payers are notified of, or participate in, decisions about transitions between levels of care.
- Coordinate discharge plans with the patient/family/significant/other, when indicated.
- Ensure discharge appointments are made in keeping with insurance requirements.
- Education & Licensure (if applicable)
- Bachelor's degree in nursing or Master's degree from an accredited college or university in social work, mental health, or related degree required.
- Experience
- A minimum of two (2) years experience in a behavioral healthcare setting or managed care company, with experience in patient assessment, treatment planning, utilization management, and/or case management.
