Utilization Review Clinician (Santa Rosa)

Northern California Behavioral Health System•Santa Rosa, CA

21d

About The Position

Work as member of multi-disciplinary treatment team reviewing patient care and treatment options for both inpatient and outpatient services. Proactively monitor and optimize reimbursement for external reviewers/third party payers. The Utilization Review Clinician maintains knowledge of, participates in further training provided, and understands the potential risks regarding occupational health hazards (e.g. bloodborne pathogen exposures).

Requirements

Current license as an LCSW, ASW, AMFT, LMFT, RN, LVN, LPT, or LPCC.
Current Cardiopulmonary Resuscitation (CPR) certification required, or obtained within initial orientation period.
Demonstrated knowledge of health care service delivery systems and third-party reimbursement
Two or more years’ experience working in managed care environment
Ability to apply and interpret admission and continued stay criteria
Strong understanding of admission and discharge function
Familiarity with medical terminology, diagnostic terms and treatment modalities
Knowledge of medical record keeping requirements
Ability to comprehend psychiatric evaluations, consults, and lab results
Maintains confidentiality of patients at all times.
Ability to cope well with stress and have a strong sense of compassion.
Sensitivity to and willingness to interact with persons of various social, cultural, economic and educational backgrounds.
Proficiency with software and/or equipment (Microsoft Office applications including Outlook, Word, Excel and PowerPoint.)
Strong organizational skills with ability to prioritize projects, work relatively independently, manage multiple tasks, and meet deadlines.
Strong written and verbal communication skills.
Strong interpersonal skills. Ability to work with people with a variety of background and educational levels.
Ability to work independently and as part of a team.
Good judgment, problem solving and decision-making skills.
Demonstrated commitment to working collaboratively as well as possessing the skills to lead, influence, and motivate others.
Ability to work in a fast-paced, expanding organization.

Nice To Haves

Preferred; Master’s degree in Social Work, Behavioral Science, or related field.

Responsibilities

Admissions: Conduct admission reviews/Pre-Authorizations in a timely manner.
Concurrent Stay Reviews: Conduct concurrent and extended stay reviews for both managed care cases and Kepro counites in a timely manner to ensure that extended stays are medically justified.
Payment Appeals: Prepare and submit appeals to third party payers in a timely manner and maintain appropriately detailed records of appeals.
Recordkeeping: Maintains appropriate records (AIS, UR forms/charts, Peer to Peer log and Medicare forms) and substantiate activity by documentation that is entered in a clear, concise, organized and timely manner.
Medical Necessity: Attend Treatment Team on a daily basis and collaborate with clinical team to answer clinical questions related to medical necessity and patient status and to advise on authorization status and denial risks.
Collaboration: Interact with physicians, case managers and other hospital colleagues in a timely, positive manner to resolve UM and patient status issues. Document UM, quality and risk concerns and refer to appropriate departments as appliable for follow up.
Denial Risk: On a daily basis, identify cases that are at risk for denial and track in log daily.
Knowledge: Demonstrate a working knowledge of Medical Necessity and regulatory standards (Medicare, Medicaid and Manage Care)
Training: Provide staff in-service training and education.
Upholds the Organization’s ethics and customer service standards.
Performs related duties, as requested.