Utilization Review Manager- Behavioral Health

Garner Behavioral Hospital LLC; United States; On-site; USD 95,000 - 120,000; Full time

Job summary

Garner Behavioral Hospital LLC in North Carolina seeks an Utilization Review Manager for Behavioral Health to lead the UR department, oversee admissions reviews, and optimize patient placement and insurance coordination. You will supervise staff, ensure compliance with standards, and coordinate with admissions and the business office for smooth operations.

The role requires nursing licensure or related clinical field expertise, several years of UR/clinical experience, and CPR/de‑escalation

Qualifications

• Requires RN or LPN licensure in the state.
• Bachelor's degree in social work, behavioral health, or related field required.
• Master's degree in same field preferred.
• Minimum four years of clinical experience with the facility's population.
• Two+ years in medical/psychiatric utilization management and supervisory experience.
• CPR and de-escalation certification required.

Responsibilities

• Assigns and supervises Utilization Review staff to ensure timely insurance verifications.
• Ensures competency to review medical records for appropriateness of level of care.
• Leads hiring, orientation, performance assessment and coaching to meet dept goals.
• Works with Admissions to verify patient information and complete pre-certification.
• Appeals denials and coordinates correspondence to ensure accuracy.
• Analyzes records to determine admission/treatment/length of stay and compliance.
• Communicates with multidisciplinary staff and managed care to resolve issues.
• Oversees reviews (concurrent/retrospective) and supports quality assurance reviews.

Skills

Leadership

Staff supervision

Regulatory compliance

Interdepartmental coordination

Communication skills

Education

RN or LPN licensure

Bachelor's degree in social work or related field

Master's degree preferred

Job description

Utilization Review Manager- Behavioral Health | Raleigh Oaks Behavioral Health | Garner, North Carolina

About the Job:

The Utilization Management Manager is responsible for the overall management of the UM department by leading and facilitating review of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria. Directs and manages the day-to-day operations and supervision of staff to obtain coverage for patients, monitors the progress of all UR cases and insurance appeals, problem solves when necessary and mitigates all issues with utilization. Monitors utilization of services and optimizes reimbursement for the facility while maximizing use of the patient’s provider benefits for their needs.

Roles and Responsibilities:

• Assigns all patients to Utilization Review staff and supervises staff to ensure staff are completing insurance verifications on time and compliant with regulatory standards and requirements.
• Ensures staff are competent to review medical records of clients for appropriateness of level of care at admission and at intervals determined by documentation in medical record and to communicate patient insurance status and needs with all disciplines.
• Leads a team of highly engaged members thru hiring, orienting, performance assessment and management, motivating, training, scheduling, and coaching to meet department goals and ensure effective and efficient department operation.
• Works closely with Admissions Department to ensure patient information is accurate and pre-certification is complete. Reviews application for patient admission and approves admission or refers case to utilization review committee for review and course of action when case fails to meet admission standards.
• Manages any discrepancies regarding stated benefit information and insurance verification, need for updated benefits or follow-up on a problem with a pre-certification from admissions.
• Appeals all denials ensuring accuracy of information and effective coordination of correspondence.
• Analyzes patient records to determine appropriateness of admission, treatment, and length of stay to comply with government and insurance company reimbursement policies. Ensures charting deficiencies are minimized and corrected timely by responsible staff. Identifies and forwards charts for review based on outlying data to the Medical Director.
• Analyzes insurance, governmental and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.
• Compares patient’s medical records to established criteria and confers with medical, clinical, nursing, and other professional staff to determine appropriateness of treatment and length of stay. Communicates and coordinates information with business office to recognize and resolve potential payment issues.
• Conducts and oversees concurrent and retrospective reviews for all patients. Assists review committee in planning and holding mandated quality assurance reviews.
• Acts as a liaison between Medicaid reviewers and the staff completing required paperwork to facilitate the Utilization Review process.
• Graduation from an accredited school of nursing OR a Bachelor's degree in social work, behavioral or mental health, or other related health field required. Master's Degree in same field preferred.
• Four or more year's clinical experience with the population of the facility required.
• Two or more years’ experience in medical/psychiatric utilization management required. Minimum of one year supervisory experience in clinical setting/utilization required.
• Comprehensive understanding of the admission, concurrent, continued stay, and retrospective reviews using the established hospital criteria.
• Ability to communicate professionally and effectively with multidisciplinary team members, managed care organizations and business office, providing needed information in a logical, concise manner using technical language that accurately describes patient’s condition.
• Current licensure as an LPN or RN or current clinical professional license or certification, as required, within the state where the facility provides services.
• CPR and de-escalation certification required (training available upon hire and offered by facility).

Why Raleigh Oaks Behavioral Health?

Raleigh Oaks Behavioral Health offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications.

Raleigh Oaks Behavioral Health is an EOE. Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.