Job Description

The Utilization Specialist is responsible for reviewing of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria which meets the daily deadlines to obtain authorizations and complete other pertinent processes. Coordinates, performs, and monitors all utilization review/management activities of the hospital to continuously improve the collection, reimbursement, coordination, and presentation of utilization review information; Educates hospital staff about requirements and trends. Performs admission, concurrent, continued stay, and retrospective reviews using the established hospital criteria. Communicates effectively with insurance companies, health maintenance organization (HMOs) and other similar entities for approval of initial or additional inpatient days for treatment. Provides information they need in a logical, concise manner using technical language that accurately describes patient’s condition and need for hospitalization. Communicates directly with physicians and other providers with respect to specific inquires and perceived trends of issues as they relate to utilization management. Appeals all denials ensuring accuracy of information and effective coordination of correspondence. Initiates, coordinates, and monitors the appeal process. Provides information to physicians to assist them in their role in appeals. Assists the admissions department with pre-certifications of care. Performs pre and post admission benefit verification with managed care organizations. Maintains accurate documentation and files as it relates to utilization management. Provides ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates. Communicates effectively with co-workers, program, and nursing staff regarding charting deficiencies and problems/issues identified. Follows up in each instance to determine if corrective action was taken. Notifies supervisor if corrective action is not completed. Coordinates information and findings with the business office to help recognize or resolve possible payment problems. Monitors patient length of stay and extensions and informs clinical and medical staff on issues that may impact length of stay. Investigates short term length of stays and endeavor to create alternate financial planning which would offer the patient extended days of treatment. Participates in discharge planning as required. Gathers and develops statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office. Conducts quality reviews for medical necessity and services provided. Facilitates peer review calls between facility and external organizations. Identifies potential review problems and discuss them with multi-disciplinary team and/or administration. Acts as liaison between managed care organizations and the facility professional clinical staff. Assists with any problems encountered during on-site or telephone reviews by the third-party payers or review organization, when necessary. 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 required. Two or more years of direct clinical experience in a psychiatric or mental health setting required. 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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