Healthcare Utilization Management Specialist

7 days ago


Charleston, West Virginia, United States Summit BHC Full time
About the Role:

The Clinical Utilization Review Specialist is responsible for conducting thorough reviews of assigned admissions, continued stays, and discharge planning to ensure compliance with established clinical criteria and regulatory requirements.

Key Responsibilities:
  • Perform admission, concurrent, continued stay, and retrospective reviews using established hospital criteria, communicating effectively with insurance companies and other entities to obtain approval for inpatient days.
  • Collaborate with physicians and other providers to address specific inquiries and trends related to utilization management.
  • Appeal denials, ensuring accuracy of information and effective coordination of correspondence, and provide information to physicians to assist in appeals.
  • Assist the admissions department with pre-certifications of care, performing pre and post admission benefit verification with managed care organizations.
  • Maintain accurate documentation and files related to utilization management.
  • Provide ongoing support and training for staff on documentation requirements, continued stay criteria, and medical necessity updates.
  • Communicate effectively with co-workers and program staff regarding charting deficiencies and problems/issues identified.
  • Coordinate information and findings with the business office to help recognize or resolve possible payment problems.
  • Monitor patient length of stay and extensions, informing clinical and medical staff on issues that may impact length of stay.
  • Gather and develop statistical and narrative information to report on utilization, non-certified days, discharges, and quality of services.
  • Conduct quality reviews for medical necessity and services provided, facilitating peer review calls between facility and external organizations.
  • Act as liaison between managed care organizations and facility professional clinical staff.
  • Assist with problems encountered during on-site or telephone reviews by third-party payers or review organization, when necessary.
Requirements:
  • Graduation from an approved/accredited school of nursing or a Bachelor's degree in social work, behavioral or mental health, or other related health field.
  • Two or more years of direct clinical experience in a psychiatric or mental health setting.
  • Current licensure as an LPN or RN or current clinical professional license or certification, as required, within the state where the facility provides services.


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