Clinical Utilization Manager
2 days ago
At Hackensack Meridian Health, we are committed to delivering exceptional patient care and advancing our mission to transform healthcare. We are seeking a highly skilled Clinical Utilization Manager to join our team.
Job Summary:The Clinical Utilization Manager will utilize clinical knowledge and understanding of behavioral health resource management to review and coordinate the care for a designated patient caseload. This role will collaborate with the attending LIP, Clinical Case Manager, nurse, and other members of the treatment team, ACCESS center staff, and PFS department to ensure appropriate utilization of resources and benefits on a case-by-case basis.
Key Responsibilities:- Perform admission reviews to ensure that the level of care criteria are met.
- Collaborate with the Access Center and Unit staff to ensure that certification is completed at the earliest possible entry into the system, and recertification occurs timely.
- Perform concurrent reviews with third-party payers and communicate potential or identified concerns to the treatment team, Director of Utilization Management, and the Medical Director.
- Review charts at identified review points and attend treatment planning conferences or team meetings, collecting data pertaining to clinical status and justifying the medical necessity for continued treatment in inpatient level of care.
- Review clinical and diagnostic interventions for appropriateness and timeliness to achieve optimal clinical and financial patient outcomes.
- Participate in interdisciplinary team meetings to ensure appropriate length of stay, review treatment interventions, and develop and implement discharge plans.
- Collaborate with Patient Financial Services, Access Center, and the clinical treatment team to ensure optimal reimbursement for services provided.
- Review concurrent denials from third-party payers with the interdisciplinary treatment team and orchestrate the appeal process where indicated.
- Anticipate patients' readiness for discharge and collaborate with primary therapists and discharge planners regarding transition to alternative levels of care.
- Perform concurrent utilization review applying identified criteria at prescribed review points and retrospective focus reviews in concordance with department objectives.
- Perform all administrative tasks related to caseload, including Meditech documentation, continuity of care referral paperwork, team, committee, or special project reports.
- Maintain competencies and professionalism by participating in educational opportunities focused on case management, psychiatric, and/or additional treatment issues/trends.
- Participate in the development and refinement of the Case Management Program.
- Participate in department and hospital committees.
- Other duties and/or projects as assigned.
- RN, BSN, or Bachelor's degree in a clinical field with a healthcare focus.
- Minimum five years of clinical experience in a behavioral health care setting.
- Excellent written and verbal communication skills.
- Proficient computer skills, including Microsoft Office and/or Google Suite platforms.
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