CLINICIAN (RN) UTILIZATION REVIEW

Responsibilities

The Utilization Review Clinician is responsible for the implementation of case management scenarios, consulting with all services to ensure the provision of an effective treatment plan for all patients.

Responds to requests for services and interfaces with managed care organizations, external reviewers and other payers. Assures good customer service practices are utilized.

Responsible for adding authorizations and denials to appropriate MIDAS screens.

Primary Responsibilities and Job Specifications

• Coordinates the response to requests for services, including the initial response, the assessment and referral process, the designation of appropriate level of care, initiating services and follow up activity.
• Reviews the effectiveness of the comprehensive interface with external reviewers, communicate with external reviewers and managed care organizations to assure timely and appropriate interactions, monitor outcomes of reviews and provide consultation as needed.
• Reviews the quality of documentation provided at all levels of care to assure adequacy and clinical appropriateness.
• Assures patients are receiving effective and appropriate treatment, based on the level of care provided.
• Ensures standards for customer relations.
• Ensures the program services offered, consulting with facility management in the planning, development implementation and evaluation of the case management program.
• Maintains current awareness of mental health activities in the community.
• Provide services to current referral sources to assure their satisfaction and continued associates.
• Ensures appropriateness of admission
• Provides necessary information for the authorization and / or reauthorization of patient admissions.
• Refers cases to the Chief Medical Officer as appropriate.
• Contacts providers as appropriate to obtain necessary information.
• Evaluates each case for quality of care; documents quality issues and appropriately refers cases to the quality management coordinator.
• Reviews selected requests for quality and follow up as necessary with the Attending Physician.
• Participates in educating providers regarding Utilization Review services, policies and procedures.
• Maintains strong working relations with internal and external customers.
• Communicates positively and professionally.
• Actively participates in monthly staff meetings.
• Maintains confidentiality in all aspects of operations.
• Effectively articulates clinical and non-clinical information to personnel of all levels of understanding.

Qualifications

Experience / Education : Graduate from an accredited program of professional nursing. Bachelor's degree is preferred. A minimum of five (5) years direct clinical experience in a psychiatric setting or mental health treatment setting required.

Experience in patient assessment, family motivation, treatment planning and communication with external review organization or comparable entities.

Licensure : RN or LPN license is required.

Additional Requirements : Trained in non-violent physical crisis intervention and CPR prior to accepting independent assignment or released from orientation.