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Utilization Review Specialist
2 months ago
The Utilization Review Specialist is a critical role at Mount Carmel Behavioral Health, an 80-bed inpatient acute treatment center for adult men and women experiencing mental or behavioral health challenges. This position serves as a liaison between managed care organizations and the facility's professional clinical staff, ensuring seamless communication and coordination of care.
Key Responsibilities- Managed Care Liaison: Act as a bridge between managed care organizations and the facility's clinical staff, facilitating effective communication and coordination of care.
- Utilization Review: Conduct reviews of insurance plans and managed care organizations, ensuring compliance with certification requirements and reimbursement regulations.
- Length of Stay Management: Monitor patient length of stay and extensions, informing clinical and medical staff of potential issues impacting length of stay.
- Reporting and Analytics: Gather and develop statistical and narrative information to report on utilization, non-certified days, discharges, and quality of services, as required by facility leadership or corporate office.
- Quality Reviews: Conduct quality reviews for medical necessity and services provided, ensuring adherence to established standards.
- Peer Review Facilitation: Facilitate peer review calls between facility and external organizations, promoting collaboration and best practices.
- Appeal Process Management: Initiate and complete the formal appeal process for denied admissions or continued stay, ensuring timely resolution.
- Pre-Certification Support: Assist the admissions department with pre-certifications of care, ensuring seamless transition of patients into treatment.
- Staff Training and Support: Provide ongoing support and training for staff on documentation, charting requirements, continued stay criteria, and medical necessity updates.
- Education: Associate's Degree in Nursing or Bachelor's Degree in Social Work, Behavioral or Mental Health required; Master's degree in Social Work preferred.
- Experience: Two (2) plus years' experience with the population of the facility and previous experience in utilization management required.
- Certifications: CPR/First Aid and De-escalation certifications required.
