About The Position
Position Summary: Facilitates a continuum of service while promoting positive outcomes and optimal reimbursement through coordination of patient care, daily clinical reviews, quality documentation, appeals, and reporting.
Requirements
- Bachelor’s Degree in Nursing, Psychology, or Social Work. Master's preferred.
- CA RN license required. License in Social Work, AMFT, Mental Health Counseling preferred
- A minimum of 3-5 years of experience working in an acute inpatient psychiatric setting as a treatment team member and/or utilization management, or years utilization management experience.
- 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's preferred.
- License in Social Work, AMFT, Mental Health Counseling 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 the payer’s criteria.
- 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 (social services, business office, Intake, Nursing) 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
- Performs other duties as assigned/required by this position
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What This Job Offers
Job Type
Part-time
Number of Employees
1,001-5,000 employees
