UTILIZATION REVIEW LICENSED SPECIALIST

Northlake Behavioral Health System -

Position Summary : Responsible for proactively monitoring the utilization of continuum services and optimize reimbursement for the system.

Reviews clinical documentation on each patient and works directly with managed care or insurance companies / entities performing concurrent, live reviews with provided clinical documentation to get additional patient days authorized for payment as needed.

Communicates with the inter-disciplinary team members to ensure optimal length of stay for patients depending on their continued medical necessity for treatment or care;

reviews and provides feedback to the Medical Director, psychiatrists, DON and clinical leaders as to quality of documentation to support continued medical necessity

Essential Functions :

Develops and maintains effective working relationship with all disciplines

Advise treatment team when clinical criteria have been inadequately documented

Obtains additional information from Medical, Nursing, and Social Services as needed to determine medical necessity for continued stay

Manages workload in an effective manner

Obtain daily clinical documentation to assess for accuracy and completeness

Organizes information daily for each case to be presented to Third party payers for continued authorization.

Conducts Precepts and / or concurrent reviews daily

Files Appeals for denials as indicated

Evaluates information in patient record for medical necessity of continued stay at current level of treatment

Assimilates all clinical information into a concise, cogent product

Completes all needed case reviews and needed follow up daily

Completes all data entry of review results in the client information system daily

Completes all data entry of review results in Approval / Denial Log daily

Communicates effectively with managed care and referral sources.

Maintains positive working and collaborative relationships with insurance and managed care providers.

Communicates with OBH Staff as needed

Inputs all data in system as needed

Ensures all documents and clinicals are gathered and sent for OBH patients as OBH Requests through email or Portal

All other duties as assigned

Minimum Qualifications :

Education : Associates Degree or higher preferred in : Nursing, social work, psychology, health information management or other healthcare field is preferred, or related experience.

May substitute Degree with High School Diploma with minimum of 4 years Psychiatric / Mental / Behavioral Health Experience.

Experience : Experience in a psychiatric setting, knowledge of health care service delivery systems, and third-party reimbursement preferred;

knowledge of managed care environment.

Competency : N / A

Licensure / Certification : Professional clinical license issued by the appropriate licensing body in Louisiana; CPR certification and CPI certifications preferred as needed

HIPAA : Has access to and adds information to the Medical Record. May only access medical record of assigned patients