Utilization Management Specialist I

SUN Behavioral Health; Houston (TX); On-site; USD 30,000 - 47,000; Part time

Benefits offered by this job

401(k) Plan with company match

Employee Assistance Program (EAP)

Employee Discount Savings Program

Job summary

SUN Behavioral Health Houston seeks a case management coordinator to support the continuum of care from admission through discharge. You will assist with authorization of admissions, process retroactive reviews and appeals, and ensure coverage for patients with managed care and Medicaid/Medicare plans.

Responsibilities include documenting patient status, coordinating with physicians and the Business Office, and participating in quality initiatives.

Qualifications

• High school diploma or GED mandatory.
• CPR and de-escalation certification required.
• Preferred LMSW/LPCa license or behavioral health/business degree.
• Minimum 1 year of healthcare experience.

Responsibilities

• Coordinate case management strategies from pre-hospitalization through discharge.
• Assist with admission authorizations and insurance documentation.
• Conduct retroactive reviews and appeals to secure coverage.
• Communicate with physicians, nursing, and insurance for patient care.
• Participate in performance improvement activities and staff meetings.

Skills

CPR certification

De-escalation skills

Healthcare experience

Education

High school diploma or GED

LMSW/LPCa license or behavioral health/business BA

Job description

Come join SUN Behavioral Houston, where our mission is to partner with communities to solve the unmet needs of those who suffer from mental illness and substance use disorders. We are a free-standing psychiatric hospital that operates 24/7 that provides a full continuum of specialized care, including inpatient and day hospital services, and offer specialized programs for children, adolescents and adults. As a member of SUN Behavorial's diverse team of professionals, you will be provided meaningful employment and a supportive culture. For more information, visit www.sunhouston.com.

Work Schedule: Variable, Monday - Friday (8a-5p)

Location: 7601 Fannin St, Houston, Texas. 77054

FTE: PRN, Non-Exempt

What We Offer

• 401(k) Plan with company match
• Employee Assistance Program (EAP)
• Employee Discount Savings Program

Position Summary

Responsible for the coordination of case management strategies pursuant to the Case Management process. Assists and coordinates care of the patient from pre-hospitalization through discharges. Responsible for assisting with authorization of admissions to hospital. Processes retroactive reviews and appeals, copies needed documentation and writes retro/appeal letters for insurance companies to ensure coverage for patient admissions. Conducts follow up calls with insurance companies to ensure coverage for patient admissions. Participates in performance improvement activities. Attends 80% of staff meetings. Coordinates care for patient through communication with Physicians, Nurse Practitioners, Clinical Services, Nursing, Assessment and Referrals Department.

Position Requirements

• Required: High school diploma or GED. CPR and hospital-selected de-escalation technique certification.
• Required: Minimum one year of experience in a healthcare setting.
• Preferred: Current unencumbered LMSW/LPCa license in the state of employment, or Bachelors degree in a behavioral health field or business administration.
• Preferred: Minimum one year experience in a Utilization Management department in behavioral health or as a Mental Health Tech
• Maintains education and development appropriate for position.
• May substitute experience for education
• May substitute education for experience

Position Responsibilities

Clinical / Technical Skills

• Provides thorough documentation and timely updates regarding patient status on log sheets that are prepared for daily meetings concerning admissions, reviews and discharges; including case s with limited benefits, cases in peer review/denial and /or unplanned discharges
• Coordinates with managed care companies or other third-party payors regarding peer reviews, retrospective reviews and appeals. Document s and updates the denial log to reflect same.
• Consults Business Office and/or admission staff as needed to clarify data and ensure authorization processes are complete.
• Documents in HCS the results of admission and concurrent reviews.
• Stays informed about changes in Medicare and Medicaid.
• Ability to stage local laws, ordinances and practices governing involuntary hospitalization and ensure compliance with same.
• Reviews the quality of documentation for each level of care to ensure clinical effectiveness and appropriateness of treatment.
• Maintains an active involvement and awareness of all patient admissions, discharges and transfers to alternate levels of care. Oversees continuity of care for each level of care transition.
• Develops and maintains processes to minimize denials and communication of same to CFO and Business Office Director.
• Reports results of daily treatment team meetings all discharges and status of high-risk case such as limited benefits, peer reviews, denials or unplanned discharges.
• Timely retroactive reviews and appeals within current month
• Strong knowledge of external review organizations (i.e.: Medicare/Managed Care/Medicaid) with knowledge of payor resources and planning.
• Types and mails all correspondence in a timely manner.
• Answers the telephone in a polite manner, Communicates information to the appropriate staff.
• Interacts with patients/families in a professional manner. Provides explanations regarding statements, insurance coverage.
• Support discharge planning and utilization review when necessary
• Perform other duties as required

Safety

• Strives to create a safe, healing environment for patients and family members
• Follows all safety rules while on the job.
• Reports near misses, as well as errors and accidents promptly.
• Corrects minor safety hazards.
• Communicates with peers and management regarding any hazards identified in the workplace.
• Attends all required safety programs and understands responsibilities related to general, department, and job specific safety.
• Participates in quality projects, as assigned, and supports quality initiatives.
• Supports and maintains a culture of safety and quality.

Teamwork

• Works well with others in a spirit of teamwork and cooperation.
• Responds willingly to colleagues and serves as an active part of the hospital team.
• Builds collaborative relationships with patients, families, staff, and physicians.
• The ability to retrieve, communicate, and present data and information both verbally and in writing as required
• Demonstrates listening skills and the ability to express or exchange ideas by means of the spoken and written word.
• Demonstrates adequate skills in all forms of communication.
• Adheres to the Standards of Behavior

Integrity

• Strives to always do the right thing for the patient, coworkers, and the hospital
• Adheres to established standards, policies, procedures, protocols, and laws.
• Applies the Mission and Values of SUN Behavioral Health to personal practice and commits to service excellence.
• Supports and demonstrates fiscal responsibility through supply usage, ordering of supplies, and conservation of facility resources.
• Completes required trainings within defined time periods, as established by job description, policies, or hospital leadership
• Exemplifies professionalism through good attendance and positive attitude, at all times.
• Maintains confidentiality of patient and staff information, following HIPAA and other privacy laws.
• Ensures proper documentation in all position activities, following federal and state guidelines.

Compassion

• Demonstrates accountability for ensuring the highest quality patient care for patients.
• Willingness to be accepting of those in need, and to extend a helping hand
• Desire to go above and beyond for others
• Understanding and accepting of cultural diversity and differences