Utilization Management Coordinator

UHS•Chicago, IL

5d•Onsite

About The Position

The Utilization Management Coordinator performs timely, daily clinical reviews with all payer types, to secure authorization for initial and continued treatment based on payer’s criteria and in accordance with the hospital wide Utilization Management Plan. Serves as liaison to 3rd and 4th party reviewers, effectively coordinating collection of all supporting data to support the hospital and patients’ position. Functions as a key member of the multidisciplinary treatment team to educate and guide on level of care requirements and payer expectations for patient acuity and appropriate utilization. Completes quality and timely appeal/denial letters. Participates in post claim recovery review and ongoing audit activity, supporting compliance with CMS and other regulators. Works collectively with hospital operations to ensure timely documentation is aligned with patient conditions. Contributes to monthly utilization data trends using hospital data tools to report for the overall operation. Facilitates physician reviews with payers as required. Maintains all records/data pertaining to the Utilization Management Program. Actively participates in Utilization Management/Medical Records Committee meetings including presentation of reports, statistics, etc. Participates in the hospital-wide Quality Assurance Program.

Requirements

Bachelor’s Degree in behavioral health related field required
Possesses knowledge of utilization review, 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.
Solid understanding of acute inpatient psychiatric hospital operations, including both mental health and substance abuse treatment

Nice To Haves

Master Degree preferred.
LCPC, LCSW, LPC, LSW, LMFT, RN or CADC preferred
1 or more years of experience in Utilization Management preferred

Responsibilities

Performs timely, daily clinical reviews with all payer types (Managed Medicare, Managed Medicaid and commercial) to secure authorization for continued treatment (i.e. by fax, telephone or on-line) based on payer’s criteria, within the payer timeframes.
Enters all relevant necessary data in Midas system including certification, denials, Medicare and appeals. Ensures all entries are accurate and entered timely, including all correspondence received
Functions as a key member of the multidisciplinary treatment team to educate and guide on level of care requirements and payer expectations for patient acuity and appropriate utilization. Active participant in multidisciplinary treatment team meetings.
Communicates to the attending provider/other disciplines within 24 hours of identification of any problems related to unmet criteria, discharge planning, documentation, etc.
Communicates with managed care/insurance reviewers on requested clinical updates within 24 hours of the certification date. Facilitating peer reviews with payers as required.
Performs other duties as assigned/required by this position.