Utilization Review Manager - MTC Phila

Progressions; Philadelphia (Philadelphia County); On-site; USD 70,000 - 100,000; Full time

Job summary

Malvern Health is seeking a full-time Utilization Review Manager in Philadelphia to lead the Utilization Review team and collaborate with the Clinical department to obtain payment certifications for stays and services.

The role requires a graduate degree and prior utilization review experience, plus strong leadership, documentation, and communication skills to ensure medical necessity is properly demonstrated and all policies are followed.

Qualifications

• Master's degree or graduate of an accredited nursing program with PA licensure.
• Prior utilization review experience preferred.
• Strong organizational and communication skills.

Responsibilities

• Maintain accurate work logs of all reviews with emphasis on documentation.
• Coordinate between clinical and UM to ensure correct level of care.
• Perform concurrent continued stay reviews using ASAM criteria.
• Communicate with insurance payers to obtain certifications and handle appeals.
• Oversee treatment engagement specialists to ensure timely authorizations.
• Identify patterns of mis-utilization and educate staff.

Skills

Leadership

Communication

Team coordination

Education

Master's degree

Nursing licensure in PA

Tools

Microsoft Office

Billing systems

Job description

Job Details: Job Location: MTC-Philadelphia - Philadelphia, PA 19131. Position Type: Full Time. Education Level: Graduate Degree. Job Shift: Day. Job Category: Health Care.

Malvern Health is currently seeking a full time Utilization Review Manager at our new state of the art building located at 3905 Ford Road. The Utilization Review Manager has supervisory responsibilities over a growing Utilization Review department and works closely with the Clinical team at Malvern. The Utilization Review Manager is a full time, exempt position offering a completive salary and comprehensive benefit package!

Position Summary

To conduct continued stay reviews of medical record documentation using pre-established criteria and to provide updated progress reports to third party payers in order to receive certification for payment. This individual will perform all utilization reviews for acute psychiatric and residential drug and alcohol clients.

To conduct continued stay reviews of medical record documentation using pre-established criteria and to provide updated progress reports to third party payers in order to receive certification for payment. This individual will perform prior authorizations/utilization reviews for residential drug and alcohol clients. Oversees the treatment engagement specialists to ensure PSA's and ASAMs and authorizations are completed and obtained in a timely manner. Helps establish engagement with new admissions.

Summary of Essential Position Functions

• Maintains accurate and thorough work logs of all reviews conducted with emphasis on documentation of service, days authorized and authorization numbers.
• Coordinates between clinical and UM to help ensure accuracy in level of care being assigned
• Coordinates reviews, appeals and maintains denial logs.
• Performs concurrent continued stay reviews using pre-established criteria. Understands Medical Necessity and ASAM criteria and communicates this information accurately to insurance carriers.
• Consults with appropriate treatment team members for clarification of documentation as needed.
• Exchanges information with Finance Office concerning insurance company requirements and all policies pertaining to certifications and appeals. Inputs data accurately for financial purposes.
• Assists supervisor and departments in identifying patterns of mis-utilization.
• Responds to telephone messages quickly, professionally and appropriately.
• Participates in continuing education to reach professional growth objectives, including maintenance of own credentials, certifications and participating in committees. Attendance at case conference for clinical updates.
• Maintains and communicates authorization information to all team members.
• Monitors/flags charts for high quality documentation when needed on a regular basis, regardless of reviews required.
• Educates new staff members about Medical Necessity criteria, high-quality documentation and insurance needs.
• Develops relationship and rapport with payers and third party insurance reviewers.
• Establishes process and procedures and trainings for the treatment engagement specialist.
• Other duties as assigned.

Supervisory Responsibilities

• Oversees the day to day operations of the Treatment Engagement specialists
  • Assign caseloads, time management, oversee appeals process.
  • Scheduling and coverage.
• Oversees the documentation and communication of in-house denials.
• Communication of medical record documentation deficiencies or lack of medical necessity criteria.
• Troubleshoot and communicate concerns with payors.
• Attends Necessary Treatment Teams and Flash

Malvern Health owns and operates inpatient services throughout southeastern Pennsylvania. Our facilities and programs treat a full range of behavioral health issues including substance use disorder, depression, anxiety, childhood disorders, behavioral issues, trauma and family issues.

Benefits

• Medical Insurance
• Dental Insurance
• Vision Insurance
• Life Insurance
• Paid Time Off
• 401K plan with company match

Staff are eligible for one on site meal per shift (free of charge!)

Qualifications

To perform this position successfully, an individual must be able to perform each essential duty satisfactorily. This position requires individuals that are client focused; team oriented; great interpersonal and communication skills; flexible to sudden changes in workload, emergency or staffing; dependable; problem solving skills; focused on compliance and performance quality. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education/Experience

Education and/or Experience: Master's Degree or graduate of an accredited nursing program with nursing licensure in the state of Pennsylvania. Previous utilization review experience preferred.

Technical/Computer Skills

Microsoft office and billing experience preferred. Requires much independent action and decision making and ability to organize own work. Knowledge of facility systems and organization as they pertain to medical records and organization review. Knowledge of medical terminology, medical record format and content.

Work Environment and Hazards

Risk of exposure to communicable disease. Possible exposure to intoxicated, disruptive, and/or agitated patients. Protected from weather conditions.

Physical Requirements

Sedentary work primarily - lifting 10 lbs. maximum

Equal Employment Opportunity

Malvern Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.