Manager Utilization Review

Santa Barbara Cottage Hospital; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

Un hôpital reconnu à Santa Barbara recherche un Manager Utilization Review pour diriger le processus de révision d'utilisation tout en travaillant étroitement avec les payeurs. Le candidat idéal doit avoir un baccalauréat, des compétences en gestion de cas et de l'expérience dans le secteur de la santé comportementale, de préférence avec des payeurs commerciaux. Cette position joue un rôle clé dans l'amélioration des processus et la qualité des soins.

Qualifications

• Baccalauréat requis, 3+ années d'expérience peuvent remplacer le diplôme.
• Expérience en révision d'utilisation, gestion de cas ou planification de sortie requise.
• Expérience préférée avec payeurs commerciaux.

Responsibilities

• Gestion du processus de révision d'utilisation, y compris la documentation clinique.
• Conduit des audits et fournit des informations aux payeurs.
• Sert de ressource pour l'équipe de soins de santé.

Skills

Utilization Review

Case Management

Patient Confidentiality

Behavioral Health

Effective Communication

Education

Bachelor's degree

Registered Nurse or Licensed Clinician

Job description

Company: Wise Path Recovery Centers

Location: Remote (must be in Eastern or Central time zone)

Ascension Recovery Services is searching for a Manager Utilization Review with SUD or behavioral health experience to join our team.

The Manager Utilization Review will be a hands-on manager and will lead the UR process, including developing policies and procedures, liaison with our 3rd party billing company and serve as the first point of escalation for payors requiring assistance in gaining additional or missing information to support authorization. This position will be responsible for ensuring procurement of authorization upon admission and discharge as well as accuracy of authorization information. The Manager will ensure timely escalation of barriers to authorization requiring clinical expertise and assist in coordination of Peer-to-Peer discussions with the payor.

Accountabilities

• Performs and documents initial certification and continued stay reviews in appropriate time frame and appropriate database; Submits clinical reviews to payors, provides information to payors supporting admission /continued stay, manages requests submitted from payors, provides discharge dates to payors, submits copies of UM activities to payors, as needed
• Obtains information from patients, caregivers, providers of services, insurance company, benefits administrators and others as necessary.
• Conveys complete and accurate clinical information to payor throughout certification process; Obtains and enters authorization numbers from payors, Verifies up-to-date concurrent authorizations.
• Research benefit data and options, programs and other forms of assistance that may be available to the client and negotiate for services as indicated.
• Communicates pertinent reimbursement information to healthcare team while observing patient right to confidentiality.
• Verifies in-network verses out-of-network benefits and communicates data to the patient and healthcare team as indicated.
• Maintains follow-up communication with payor as required; confirms certification date with payor at time of discharge.
• Documents obtained financial information in a complete, timely and concise manner.
• Identifies trends in care, processes or services that may provide opportunities for improvement in a patient population, provider population or service unit.
• Takes initiative to participate in a quality/process improvement initiative.
• Identifies quality and risk management issues; refers issues for corrective action as appropriate.
• Observes at all times legal and ethical considerations pertaining to client confidentiality.
• Serves as a resource for other members of the healthcare team by participates in or conducts formal/informal in-service education as indicated
• Promote and adhere to the workplace values of integrity, respect, trust, teamwork, quality, and excellence

Education, Experience, Skills

• Bachelor's degree required, 3+ years of experience may be substituted for degree
• Registered Nurse or Licensed Clinician preferred
• 3+ years of experience in utilization review, case management, or discharge planning
• Experience in a Behavioral Health/SUD facility providing multiple levels of care required
• Experience with commercial payors strongly preferred