Job Description
Responsibilities
JOB SUMMARY : Performs timely, daily pre-certifications, to secure initial authorization based on payer’s criteria and in accordance with the hospital wide Utilization Management Plan.
Coordinates with the Business Office, Admissions Department and Utilization Management Department. Obtains billing and insurance information, verification of benefits, communicates problematic benefit verification with Business Office, etc.
Update patient accounts to ensure accurate demographic information. Advocates on behalf of the patient to ensure the appropriate level of care, including appropriateness of the admission.
Knowledgeable and able to explain Hospital programs, services, and treatment goals. Understands and considers basic growth and development needs specific to the age and population served.
Provides accurate and complete information to payers regarding reason for admissions. Assures compliance with all applicable laws, codes, rules, and regulations that pertain to psychiatric admissions.
Trains other staff in the pre-certification process, policies, and procedures. Obtains, organizes, and has current information regarding initial authorizations, pending authorizations, and initial denied authorization.
Maintains all data / records regarding the pre-certification process. Participates in the hospital-wide Quality Assurance Program.
Qualifications
JOB SPECIFICATIONS : To perform this job successfully, an individual must be able to perform each primary duty satisfactorily.
The requirements listed below are representative of the knowledge, skill and / or ability required.
Education : Bachelor’s Degree in Behavioral Health Field required; Master Degree preferred.
Experience : 1 year experience in Utilization Management; 1 year experience in mental health / psychiatry preferred
Licensure / Certification : None
Knowledge : Working knowledge of Illinois Confidentiality Act, ILPA process and detailed understanding of psychiatric criteria for various levels of care.
Possesses knowledge of utilization management, insurance and managed care procedures. Current knowledge of regulating / accrediting agency guidelines.
Basic knowledge of computer skills and statistical analysis desired. Knowledgeable in behavioral health managed care and clinical assessment skills to align patient acuity with level of care practice guidelines - Diagnostic and Statistical Manual of Mental Disorders (DSM-V).
Effective oral and written communication skills to support patient advocacy / negotiating skills to ensure quality reviews with payers.
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