Utilization Management Coordinator PT

Position Summary:

Facilitates a continuum of service while promoting positive outcomes and optimal reimbursement through coordination of patient care, daily clinical reviews, quality documentation, appeals, and reporting.

QUALIFICATIONS

Education: Bachelor's Degree in Nursing, Psychology, or Social Work. Master's preferred.

Licensure: CA RN license required. License in Social Work, AMFT, Mental Health Counseling preferred

Experience: A minimum of 3-5 years of experience working in an acute inpatient psychiatric setting as a treatment team member and/or utilization management, or years utilization management experience.

Shift time: Sunday- Thursday 8:00 am-4:30 pm

1. Knowledgeable in behavioral health managed care and clinical assessment skills to align patient acuity with level of care practice guidelines - Diagnostic and Statistical Manual of Mental Disorders (DSM-V).
2. Effective oral and written communication skills to support patient advocacy/negotiating skills to ensure quality reviews with payers
3. Solid understanding of acute inpatient psychiatric hospital operations, including both mental health and substance abuse treatment.

Essential Job Duties/Responsibilities

1. Performs timely, daily clinical reviews with all payer types (Managed Medicare, Managed Medicaid and commercial) to secure authorization for continued treatment (i.e. by fax, telephone or on-line) based on the payer's criteria.
2. Functions as a key member of the multidisciplinary treatment team to educate and guide on level of care requirements and payer expectations for patient acuity and appropriate utilization.
3. Completes quality and timely appeal/denial letters. Participates in post claim recovery review and ongoing audit activity, supporting compliance with CMS and other regulators
4. Works collectively with hospital operations (social services, business office, Intake, Nursing) to ensure timely documentation is aligned with patient conditions.
5. Contributes to monthly utilization data trends using hospital data tools to report for the overall operation
6. Facilitates physician reviews with payers as required
7. Performs other duties as assigned/required by this position

Equal Employment Opportunity

It is the policy of the facility to provide equal opportunity in employment to all employees and applicants for employment. No person will be discriminated against in employment based on race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state, or local laws.

Americans with Disabilities Act

Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.

Service Excellence.

Service excellence is a part of all we do. Our standards include:

• Treat everyone as a guest by making a good first impression, anticipating needs and displaying service recovery skills.
• Demonstrate professionalism and excellence by looking professional, being accountable for actions and delivering excellence in our everyday work.
• Practice teamwork by participating in decision making and process improvement, communicating effectively and focusing on the problem/issue, not the person.