- At least two years psychiatric/chemical dependency experience with good working psychiatric/medical knowledge
- Qualifications / Skills:Must have excellent assertive communication skills and leadership skills
- Knowledge and in-depth understanding of CD/psych treatment and discharge planning process
- Must have good writing and composition skills
- Must have good understanding of regulatory and fiscal reimbursement and utilization review as a primary component of patient care
- Must demonstrate strong patient advocacy skills
- Must be able to organize and prioritize high volume workload
- Must be able to analyze and utilize data and systems to provide individualized quality treatment in a cost-effective manner
- Must be able to function with minimal supervision
- Therapeutic Intervention De-escalation Education required
- Must have ability to maintain overall good work attitude and interact cooperatively and professionally with other staff members and third party payers to achieve mutually beneficial outcome
- Must possess basic competency in age/disability/cultural diversity needs of patients served and ability to relate to patients in a manner sensitive to those needs
- Must successfully complete CPR certification and an Oceans approved behavioral health de-escalation program
- Work Environment:Subject to many interruptions
- Occasional pressure due to multiple calls and inquiries
- This position can be high paced and stressful; must be able to cope mentally and physically to atmosphere
Responsibilities
- The Director of Utilization Review is responsible for management of all utilization review/case management activities for the facility's inpatient, partial hospitalization, and outpatient programs
- The Director of Utilization Review, along with the Clinical Director, oversees the UR Coordinators in the department and is there to help when asked
- Conducts concurrent reviews of all medical records to ensure criteria for admission and continued stay are met and documented, and to ensure timely discharge planning
- Coordinates information between third party payers and medical/clinical staff members
- Interacts with members of the medical/clinical team to provide a flow of communication and a medical record which documents and supports level and intensity of service rendered
- All duties to be done in accordance with Joint Commission, Federal and State regulations, Oceans' Mission, policies and procedures and Performance Improvement Standards
- Identifies and reports appropriate use, under-use, over-use and inefficient use of services and resources to ensure high quality patient care is provided in the least restrictive environment and in a cost-effective manner
- Conducts review of all inpatient, partial hospitalization, and outpatient records as outlined in the Utilization Review/Case Management plan to (1) determine appropriateness and clinical necessity of admissions, continued stay, and or rehabilitation, and discharge; (2) determine timeliness of assessments and evaluations; i.e
- H&Ps, psychiatric evaluation, CIA formulation, and discharge summaries; and (3) identify any under-, over-, and/or inefficient use of services or resources
- Reports findings to appropriate disciplines and/or committees; notifies appropriate staff members of any deficiencies noted so corrective actions can be taken in a timely manner; submits monthly report to PI Coordinator of findings and actions recommended to correct identified problems
- Coordinates flow of communication between physicians/staff and third party payers concerning reimbursement requisites; conducts telephone reviews and follows through with documentation requests from third party payers; maintains abstract with updates provided to third party payers
- Attends mini-treatment team and morning status meetings each weekday to obtain third-party payer pre-certification and ongoing certification requirements and to share with those attending any pertinent data from third-party payer contracts; also attends weekly treatment team
- Notifies physicians/staff/patients of reimbursement issues; initiates and completes appeals process for reimbursement denials; notifies inpatients of denials received; reports monthly all Hospital Issued Notices of Non-coverage (HINN letter) to QIO
- Upon notification by business office that potential exists to be included on a new managed care contract, makes contact with the managed care company and coordinates communications between administration and the managed care company to obtain contractual arrangements
- Maintains coordination of information requests from third party payers for annual renewal or update of existing contracts
- Communicates to staff status of new/existing contracts
- Performs case management duties as required and coordinates flow of communication among staff involved in the patient's care; completes paperwork for judicial commitments and state bed packets
- Completes referral process and necessary paperwork for all other levels of care and make follow-up appointments; including follow up letters needed by the patient
- Conducts special retrospective studies/audits when need is determined by M&PS and /or other committee structure
- Performs other duties and projects as assigned
Job Type: Full-time
Pay: $25.00 - $35.00 per hour
Expected hours: 40 per week
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Schedule:
Application Question(s):
- How many years have you done utilization review for substance abuse?
- Have you been able to obtain long authorizations for each level of care for the payor BCBS?
- Are you able to start immediately or need two weeks?
Work Location: Remote
