Behavioral Health Utilization Review Specialist

Hiring for Full Time and PRN

Are you a detail-oriented and results-driven healthcare professional with a passion for ensuring the highest quality of patient care?

We are seeking a dedicated Utilization Review Manager to join our team! As the Utilization Review Manager, you will play a critical role in establishing and maintain efficient methods of ensuring the medical necessity and appropriateness of hospital admissions while overseeing daily operations and supervising the staff performing concurrent reviews for patients to ensure that extended stays and medically justified and are so documented in patient’s medical records.

If you are a highly organized and analytical professional with a strong commitment to quality and efficiency, we encourage you to apply.

• Completes daily reviews on all patients and oversees the communication of those reviews to all requesting insurance companies per agreement.
• Updates the Utilization Review Plan to meet CMS requirements for CoP.
• Receives all denials for care involving patient stays. Manages all appeals related to denials of patient stays for all payer/insurance companies.
• Participates in quality improvement processes and assures implementation of regulatory standards.
• Researches interdepartmental problems/issues and takes corrective action in timely manner and promotes respectful responsive communication between departments to promote patient centered care.
• Oversees and performs concurrent reviews for patients to ensure that extended stays are medically justified and are so documented in the patients’ medical record.
• Coordinates and supervises all activities of the Utilization Review Department.
• Identifies problems related to the quality of care and refers them to the Quality Department.
• Maintains communication with the Social Service Department to facilitate timely discharge planning.
• Must be able to effectively work with large amounts of confidential data and protected PHI.
• Ensures that all continued stay, concurrent review and utilization review activities are carried out in accordance with facility policy, evidence-based industry standards and applicable laws or regulations.
• Oversees function of Utilization Specialist which includes:
  • Performs insurance verification and ongoing concurrent reviews. Assists hospital business office with matters related to insurance reimbursement
  • Conducts himself/herself in a professional manner in compliance with unit and hospital policies.
  • Appeals denials through the payer’s appeal process and coordinates with the billing department.
  • Monitors the patient’s clinical progress as well as that of the treatment plan.
  • Collaborates with the attending physician and treatment team to facilitate patient conferences which develop, monitor and refine the treatment plan to achieve identified patient outcomes.
  • Attends treatment team to identify patient needs related to diagnosis, treatment, prognosis, and projected date of discharge.
  • Works with physician and treatment team to review orders regarding consults, DME, and discharge plans to ensure compliance with the patient’s insurance company.
  • Maintains internal tracking documents and spreadsheets on a daily basis and/or s instructed

• Associate’s or Bachelor’s degree in nursing required. 
• 3-5 years of post-licensure experience in a combination of Behavioral Health or Case Management.    
• Must have a current license to practice profession in state. (RN, LPN). Must be certified in CPR
• Must have a reliable source of transportation.  
• Must have a valid driver’s license and automobile insurance
• Excellent verbal and written communication skills.
• Excellent organizational skills and attention to detail.
• Excellent time management skills with a proven ability to meet deadlines.
• Proficient with Microsoft Office Suite or related software.
• Ability to effectively utilize electronic medical records software.
• Ability to maintain confidentiality. Reliable transportation required

All of our employees are valued and receive a competitive wage; full time team members are also offered a comprehensive benefit package which includes: 

• Medical, Dental, Vision, Life and Disability Insurance/ Flexible Spending Accounts
• Tuition Reimbursement & Nursing Loan Repayment Programs
• PerkSpot - Local Deals and Weekly Perks Program
• 401(k)
• Paid Time Off Plan
• New Pet Insurance Discount available
• DailyPay option available! – Get your pay, when you need it.
• Purchasing Power - online purchase/payroll deduction
• Tickets at Work - entertainment ticket discounts
• Employee Assistance Plan - easy-to-use services to help with everyday challenges of life (available for all employees and their families) 
• Helping Friends Foundation - our employees’ hardship/crisis fund
• Auto and Home Insurance - employee discount available – payroll deduction!
• In-facility education programs and more!

Drug Free, Smoke-Free work place. Equal Opportunity Employer, including disability/vets