Utilization Management Coordinator (H)

Saint Francis Health System

2d•Onsite

About The Position

Provides administrative and clinical support to the hospital and treatment team throughout the review of patients, their placement in various levels of care and their receipt of necessary services and appropriate discharge planning. UM Coordinators participate in treatment teams, communicating with providers the details of reimbursement issues; also participates in the Patient Care Committee for patient care reviews, and in Utilization Review Staff Committee, providing data and contributing to improvement of internal processes. Provides staff education as needed to further the goals of UR. Minimum Education: Has completed the basic professional curricula of a school of nursing as approved and verified by a state board of nursing, and holds or is entitled to hold a diploma or degree therefrom or Master's degree in Social Work, Counseling or related behavioral health field.

Requirements

Valid multi-state or State of Oklahoma Registered Nurse License, or Clinical Social Worker (LCSW), or Professional Counselor (LPC) license, or Marriage and Family Therapist (LMFT).
3 - 4 years of related experience in behavioral health care, part of which may be experience in Behavioral health managed care.
Working knowledge of Microsoft Word, Excel and Access as might be used in the preparation of correspondence and reports.
Effective interpersonal, written and oral communication skills.
Ability to integrate the analysis of data to discover facts or develop knowledge, concepts or interpretations.
Ability to organize and prioritize work in an effective and efficient manner.
Ability to be detail oriented as required in the examination of numerical data.
Ability to synthesize clinical case data into concise summaries.

Responsibilities

Meets time requirements for review intervals, supplying the required clinical information to obtain authorization.
Responds promptly to authorizing entity's need for further detail.
Participates in treatment team or Patient Care Committee, providing information about eligibility, benefits and criteria for the selected level of care.
Seeks treatment information for use in providing reviews for authorization of services.
Contributes to discharge planning.
Participates in quality of care process improvement.
Identifies QI Triggers for individual patient situations, reporting them promptly to the Process Improvement/Quality Director, to appropriate clinicians and to the UM Manager.
Reviews eligibility and benefits of patients, matching the level of care utilization.
Assures compliance with Managed Care Behavioral Health standards in the area of UM procedures and documentation to permit accreditation for Laureate and/or to maintain the delegation standards established by the managed care contracts.
Investigates and prepares appeals for insurance companies, when denial of reimbursement is related to medical necessity or to other treatment issues.
Participates in UM process improvement on an ongoing basis and participates in the UR Staff Committee's process improvement goals.