Utilization Review Licensed Specialist

6 days ago


Mandeville, United States Northlake Behavioral Health System Full time
Northlake Behavioral Health System -

Position Summary: Responsible for proactively monitoring the utilization of continuum services and optimize reimbursement for the system. Reviews clinical documentation on each patient and works directly with managed care or insurance companies/entities performing concurrent, live reviews with provided clinical documentation to get additional patient days authorized for payment as needed.  Communicates with the inter-disciplinary team members to ensure optimal length of stay for patients depending on their continued medical necessity for treatment or care; reviews and provides feedback to the Medical Director, psychiatrists, DON and clinical leaders as to quality of documentation to support continued medical necessity

 

Essential Functions:

 

·         Develops and maintains effective working relationship with all disciplines

·         Advise treatment team when clinical criteria have been inadequately documented

·         Obtains additional information from Medical, Nursing, and Social Services as needed to determine medical necessity for continued stay

·         Manages workload in an effective manner

·         Obtain daily clinical documentation to assess for accuracy and completeness 

·         Organizes information daily for each case to be presented to Third party payers for continued authorization.

·         Conducts Precepts and / or concurrent reviews daily

·         Files Appeals for denials as indicated

·         Evaluates information in patient record for medical necessity of continued stay at current level of treatment

·         Assimilates all clinical information into a concise, cogent product

·         Completes all needed case reviews and needed follow up daily

·         Completes all data entry of review results in the client information system daily

·         Completes all data entry of review results in Approval /Denial Log daily

·         Communicates effectively with managed care and referral sources.

·         Maintains positive working and collaborative relationships with insurance and managed care providers.

·         Communicates with OBH Staff as needed

·         Inputs all data in system as needed

·         Ensures all documents and clinicals are gathered and sent for OBH patients – as OBH Requests through email or Portal

·         All other duties as assigned

 

Minimum Qualifications:

Education: Associate’s Degree or higher preferred in: Nursing, social work, psychology, health information management or other healthcare field is preferred, or related experience. May substitute Degree with High School Diploma with minimum of 4 years Psychiatric/Mental/Behavioral Health Experience.

Experience: Experience in a psychiatric setting, knowledge of health care service delivery systems, and third-party reimbursement preferred; knowledge of managed care environment.

Competency: N/A

Licensure/Certification: Professional clinical license issued by the appropriate licensing body in Louisiana; CPR certification and CPI certifications preferred as needed

HIPAA: Has access to and adds information to the Medical Record.  May only access medical record of assigned patients



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