Utilization Review Coordinator - CARES - Jackson, MS

Canopy Children's Solutions•Jackson, MS

3d•Onsite

About The Position

The Utilization Review Coordinator acts as a liaison between the organization and the Peer Review Organization (PRO), the physicians, the Interdisciplinary Treatment Team, the Managed Care Organization and Administration. This position coordinates the utilization management of behavioral health services for all programs requiring pre-certification for admission. The Utilization Review Coordinator coordinates all aspects of the concurrent review process and discharge process in collaboration with the assigned clinical staff. Participates in the organization’s performance improvement and quality compliance process.

Requirements

Minimum of a Bachelor's degree required, Master's degree preferred in a social science field such as Psychology, Education, and/or Social Work or a social rehabilitative field.
Minimum of two (2) years' experience in a behavior health setting.
Minimum one (1) year of experience working with children and adolescents.

Responsibilities

Assists in coordinating the interdisciplinary treatment teams.
Attends staffing, treatment team meetings and clinical communities as applicable for coordination of care and transitional planning for aftercare/discharge services.
Reviews, evaluates and reports prior authorization, concurrent reviews, and discharges as required by the Peer Review Organization (PRO) and Managed Care Organizations (MCOs) for review.
Acts as the utilization liaison to the Managed Care Organizations, the Division of Medicaid and its Peer Review Organization (PRO) to facilitate the prior authorization process as needed.
Utilizes clinical documentation from the electronic health records for children and youth to request concurrent reviews, extensions of using the prior authorization process.
Facilitates the prior authorization and continued stay process and coordinate the review of required documentation with the Medical Director, Psychiatrists, and clinical teams assigned to obtain approval for concurrent reviews and continued stays through the prior authorization process for the PRO and Third Party Payers.
Manages required upload of required documentation to external reviewer sites for the purpose of supporting the prior authorization approval and lock in process.
Coordinates discharge planning with the solution/clinical team to ensure timely discharges.
Conducts weekly verification of insurance and eligibility checks and notify solution staff and Director as applicable of status. Input verification documentation in the electronic health record.
Assists in resolving billing holds and reimbursement errors as requested and needed by the accounting/billing department related to prior authorization approvals.
Facilitates the clinical review of the appeal process for denials of concurrent reviews as needed, if applicable.
Assists in the development of policies and procedures related to utilization management, treatment planning, concurrent reviews and discharges as necessary.
Assures that all processes and documentation meet Division of Medicaid, PRO, Third Party Payers and the organization’s standards by reviewing records and clinical documentation for compliance and quality assurance.
Monitors authorizations approvals for upcoming expiration to facilitate either a discharge or concurrent review using utilization management reports in the electronic health record.
Monitors medical necessity criteria regularly and facilitate the utilization management process.
Analyzes patient records to determine legitimacy of admission and treatment in accordance with the external reviewers and regulatory organizations’ medical necessity criteria.
Provides coverage for admissions staff duties as assigned and requested to ensure overall work goals are accomplished within the department.
Maximizes revenue by tracking and managing reimbursement issues; identifying and recommending potential opportunities; and preventing revenue-reducing clerical errors.
Promotes Canopy Children’s Solutions to the public.
Appropriately utilize and accept supervision.
Promotes the organization's Core Values and Mission.
Adheres to identified and established work schedule.
Performs other responsibilities and duties as requested and/or assigned by the Director of Admissions and/or Leadership.
Adheres to organizational policies and procedures.
Meets all key performance indicators (KPI).
Provides weekly reports on service delivery and utilization of services for identified solutions within the organization to the Director of Admissions and upon request as needed.
Provides prior authorization status, utilization reports, and eligibility status reports to Director of Admissions, admissions team, and solution team weekly and upon request as needed.
Provides status update of any cases in appeal as applicable to Director of Admissions and admissions department staff and solution staff assigned as needed and requested.
Provides monthly reporting of quality review samples for auditing.