BH Utilization Mgmt Coord-PMM

Piedmont Healthcare; Macon (GA); On-site; USD 70,000 - 95,000; Full time

Job summary

Piedmont Healthcare Corporate is seeking a clinician to ensure admitted behavioral health patients receive appropriate care and meet medical necessity for continued stay and authorizations.

The role tracks progress of the plan of care and ensures payor information supports authorization for continued services, including covered days. The ideal candidate holds an RN in GA or LMSW/LCSW, or LPC/LMFT, with experience in Utilization Management and guidelines such as InterQual/MCG.

Qualifications

• Bachelor’s degree from an accredited nursing school and RN licensure in GA.
• Bachelor’s degree in Social Work required; Master’s degree preferred.
• 2 years in acute/post-acute/managed care, or revenue cycle required.
• Experience with InterQual and/or MCG guidelines required.
• Experience in Utilization Management and/or Appeals preferred.
• Current/unrestricted RN license or LMSW/LCSW in GA; LPC/LMFT also acceptable.

Responsibilities

• Ensure admitted patients receive appropriate level of care and meet medical necessity.
• Monitor progress of patient plan of care and continued stay authorizations.
• Provide payer with clinical information to authorize services and covered days.

Education

Bachelor's Degree - nursing (RN)

Bachelor's Degree in Social Work

Master's Degree Preferred

Tools

Epic

Meditech

MIDAS

InterQual/MCG guidelines

Prior authorization systems

Job description

Overview:

The purpose of this position is to ensure that admitted patients have the appropriate level of care, patient status, authorization status, plan of care and meet medical necessity for the behavioral health services. This role monitors that the patient is progressing in their plan of care and meet medical necessity for continued stay. This role ensure that patient's payor has the clinical information with which to authorize the behavioral health service and continued stay service to include covered days and associated services.

Responsibilities:

The purpose of this position is to ensure that admitted patients have the appropriate level of care, patient status, authorization status, plan of care and meet medical necessity for the behavioral health services. This role monitors that the patient is progressing in their plan of care and meet medical necessity for continued stay. This role ensure that patient's payor has the clinical information with which to authorize the behavioral health service and continued stay service to include covered days and associated services.

Qualifications:

Education

• Bachelor's Degree from an accredited nursing school, B.A/ B.S Required or
• Bachelor's Degree in Social Work Required
• Master's Degree Preferred

Work Experience

• 2 years of experience in an acute, post-acute, managed care, psychiatric, or revenue cycle Required
• Previous experience with InterQual and/or MCG guidelines Required
• Previous experience in Utilization Management and/or Appeals Required
• Previous Epic experience or Meditech/MIDAS experience Required
• Previous experience in prior authorization process Required
• Utilization Review or Care Management experience Preferred

Licenses and Certifications

• Current unrestricted registered nurse (RN) license or LMSW/LCSW, in the state of Georgia. Upon Hire Required or
• LPC/LMFT also acceptable Upon Hire Required
• CCM - Certified Case Manager Case Management Certification (CCM) or American Case Management Association (ACMA) certification Preferred

Business Unit : Company Name:

Piedmont Healthcare Corporate