Utilization Review Manager - MTC Phila

MALVERN INSTITUTE FOR PSYCHIATRIC & ALCOHOLIC STUDIES•Philadelphia, PA

7d•Onsite

About The Position

Malvern Health is currently seeking a full time Utilization Review Manager at our new state of the art building located at 3905 Ford Road. The Utilization Review Manager has supervisory responsibilities over a growing Utilization Review department and works closely with the Clinical team at Malvern. The Utilization Review Manager is a full time, exempt position offering a competitive salary and comprehensive benefit package! Position Summary: To conduct continued stay reviews of medical record documentation using pre-established criteria and to provide updated progress reports to third party payers in order to receive certification for payment. This individual will perform all utilization reviews for acute psychiatric and residential drug and alcohol clients. Position Summary: To conduct continued stay reviews of medical record documentation using pre-established criteria and to provide updated progress reports to third party payers in order to receive certification for payment. This individual will perform prior authorizations/utilization reviews for residential drug and alcohol clients. Oversees the treatment engagement specialists to ensure PSA’s and ASAMs and authorizations are completed and obtained in a timely manner. Helps establish engagement with new admissions.

Requirements

Master's Degree or graduate of an accredited nursing program with nursing licensure in the state of Pennsylvania.
Previous utilization review experience preferred.
Microsoft office and billing experience preferred.
Requires much independent action and decision making and ability to organize own work.
Knowledge of facility systems and organization as they pertain to medical records and organization review.
Knowledge of medical terminology, medical record format and content.
Client focused; team oriented; great interpersonal and communication skills; flexible to sudden changes in workload, emergency or staffing; dependable; problem solving skills; focused on compliance and performance quality.

Nice To Haves

Previous utilization review experience
Microsoft office and billing experience

Responsibilities

Maintains accurate and thorough work logs of all reviews conducted with emphasis on documentation of service, days authorized and authorization numbers.
Coordinates between clinical and UM to help ensure accuracy in level of care being assigned
Coordinates reviews, appeals and maintains denial logs.
Performs concurrent continued stay reviews using pre-established criteria. Understands Medical Necessity and ASAM criteria and communicates this information accurately to insurance carriers.
Consults with appropriate treatment team members for clarification of documentation as needed.
Exchanges information with Finance Office concerning insurance company requirements and all policies pertaining to certifications and appeals. Inputs data accurately for financial purposes.
Assists supervisor and departments in identifying patterns of mis-utilization.
Responds to telephone messages quickly, professionally and appropriately.
Participates in continuing education to reach professional growth objectives, including maintenance of own credentials, certifications and participating in committees. Attendance at case conference for clinical updates.
Maintains and communicates authorization information to all team members.
Monitors/flags charts for high quality documentation when needed on a regular basis, regardless of reviews required.
Educates new staff members about Medical Necessity criteria, high-quality documentation and insurance needs.
Develops relationship and rapport with payers and third party insurance reviewers
Establishes process and procedures and trainings for the treatment engagement specialist
Oversees the day to day operations of the Treatment Engagement specialists
Assign caseloads, time management, oversee appeals process.
Scheduling and coverage
Oversees the documentation and communication of in-house denials.
Communication of medical record documentation deficiencies or lack of medical necessity criteria.
Troubleshoot and communicate concerns with payors.
Attends Necessary Treatment Teams and Flash
Other duties as assigned