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:

8 hour shift

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

Safe Haven Detox jobs

Utilization Review Specialist (Remote)