Utilization Review Clinician - CST hours

Monte Nido & Affiliates, LLC

12h•Remote

About The Position

Monte Nido has been delivering treatment for eating disorders for over two decades. Our programs offer a model of treatment that blends medically sophisticated care with a personalized treatment approach. Our work is grounded in evidence-based strategies for adults and adolescents suffering from eating disorders. We work from a multi-disciplinary treatment team approach while integrating state-of-the-art medical, psychiatric, nutritional, and clinical strategies to provide comprehensive care within an intimate home setting. The Utilization Review Clinician is responsible for conducting daily administrative and professional support that enables claims to be correctly processed and retained in accordance with departmental policies and procedures. The specific functions performed by this role are critical in achieving the Revenue Cycle Team’s overall responsibilities involving timely billing and account follow-up. This is a Full Time remote position supporting our virtual programs on East and West coasts. #LI-REMOTE VIRTUAL EMPLOYEES: We have the same expectations for employees as we do for clients. We ask that you always have camera on and join from a private space free from other noises and distractions (e.g. not in car) when meeting with clients or joining a clinical staff meeting. You will need a reliable video conferencing setup including camera, microphone and stable, high speed Internet connection. You will also need to be prepared for a back-up in the event of technology failures. We also expect that you consider your personal appearance in much the same way you would if you were seeing clients in-person. You will also need to keep your background (behind the camera) clean and professional.

Requirements

Master’s degree in counseling, social work or an LMSW, LCSW, LICSW, LPC, LMHC, or Bachelor’s Degree in nursing preferred.
Licensed and currently registered in the state you are working strongly preferred.
Available to work 8-4:30pm CST Mon-Fri.
A minimum of one year of experience of facility based care and knowledge relating to utilization review methods, insurance authorizations, Medicare, Medicaid, and managed care preferred.
Knowledge of The Joint Commission standards.
Knowledge of the Principles and Practices of the discipline.
Knowledge of Joint Commission Standards.
Demonstrates Proficiency in Communication & Written skills.
Working knowledge of State & Federal Statutes Regarding Patient Confidentiality laws.
Knowledge of Drug-Free Workplace Policies.
Knowledge of Workplace Violence.

Responsibilities

Complete and manage all authorizations for designated programs & departments including single case agreements, prior authorization, continued stay, change in level of care, discharge, peer-to-peer, and manage denials through all levels of appeal.
Support treatment team members & Admissions by discussing services covered by the members benefits and reviewing clinical documentation needed to successfully advocate for our clients.
Engage in clinical rounds as an active treatment team member providing payor needs for next review, guidance on level of care recommendations, and feedback on what will be needed for authorization of clinically indicated services.
Expectation to provide coverage support across all Admission Hubs and UM Department staff as needed.
Responsible for supporting Admissions and program treatment team members in understanding how payors determine medical necessity, documentation needs, auth process, and determination timeline to provide the highest level of advocacy and efficiency possible.
Understanding of Medicare medical necessity criteria.
Communicates with Revenue Cycle Management and Contracting regarding billing/claims issues and status of single case agreements as needed.
Communicates with admissions and programs regarding status of client authorization, potential denials, and potential for private payment.
Leverage understanding of medical necessity criteria and current behavioral health insurance landscape in verbal and written communications with payors to maximize our clients’ access to care and decrease peer to peer reviews.
Follows standardized processes and clinical documentation.
Communicates emerging trends with insurance companies to Clinical Director.
Contribute to department projects and maintain reporting requirements.
Apply understanding of payors medical necessity criteria in communications with payors.
Maintain up to date knowledge of parity, payor & market trends, Medicaid and Medicare benefits, plan structure, and medical necessity criteria.
Maintain up to date knowledge of all MN programs, treatment innovations, and research.
Deliver care in a non-judgmental and non-discriminatory manner, sensitive to patient and staff diversity.
Attends in-services and educational training as necessary and as assigned.
Seeks out learning experiences and incorporate new knowledge into practice.
Maintains flexibility and adaptability to expected and unexpected changes in the work environment.
Reports incidents, accidents, and occurrences in accordance with policies and procedures.
Maintains safety of the physical environment.
Complies with facility policies and procedures.
Ensures all interactions (phone, email, meetings, etc.) are in line with the organization’s mission and values.
Performs other tasks, as assigned.