The Utilization Review Specialist is an essential role at Mount Carmel Behavioral Health, an -bed inpatient acute treatment center for adult men and women who have been / currently are experiencing a wide range of mental or behavioral health challenges.
The Utilization Review Specialist at Mount Carmel Behavioral Health, a joint partnership between Acadia Healthcare and Mount Carmel Health Systems, will serve as a partner to the UM department and other departments through the facility as a bridge between impacting direct patient care and financial stability of the facility.
Essential Functions include but not limited to :
- Act as liaison between managed care organizations and the facility professional clinical staff.
- Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
- Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
- Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
- Conduct quality reviews for medical necessity and services provided.
- Facilitate peer review calls between facility and external organizations.
- Initiate and complete the formal appeal process for denied admissions or continued stay.
- Assist the admissions department with pre-certifications of care.
- Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.
Educational / Licensure / Skills Requirements :
- Current and valid Licensed LPN in state of Ohio preferred.
- Associate's Degree in Nursing OR Bachelor's Degree in Social Work, behavioral or mental health required. Master's degree in social work preferred.
- Two () plus years' experience with the population of the facility and previous experience in utilization management required.
- CPR / First Aid and De-escalation certifications required.
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