Utilization Review (UR) / Utilization Management (UM) Coordinator

UHS•Moultrie, GA

3d•Onsite

About The Position

Turning Point Care Center provides comprehensive behavioral health care for adults experiencing chemical dependency, acute psychiatric disorders, or a dual diagnosis. For more than 40 years, our team has provided a place of healing and hope through a full continuum of inpatient and outpatient care, with programs tailored to meet each patient’s unique needs. Nestled in a serene, rural setting in Moultrie, Georgia, Turning Point offers a calming, secure environment where patients can focus on recovery and build a foundation for lifelong wellness. Our commitment to quality care is grounded in the belief that healthy communities begin with healthy individuals and strong connections to family, friends, and peers. Centrally located in South Georgia, our facility is just 30 minutes from I-75, 1.5 hours north of Tallahassee, 3 hours south of Atlanta, and 2.5 hours west of Jacksonville. Turning Point offers a rewarding opportunity to build a career while making a meaningful difference in the lives of those we serve. The Utilization Review / Utilization Management Coordinator oversees utilization management functions to monitor the appropriateness and continuity of patient care while optimizing reimbursement. This position conducts clinical reviews, monitors patient records and treatment plans, communicates with insurance providers and treatment team members, and ensures compliance with applicable requirements.

Requirements

Licensed through state board for Nursing or Counseling/Therapy
RN, LMSW, LAPC, or LAMFT required
Three years’ experience in chart analysis, utilization review, medical/clinical terminology, and acuity of illness
Knowledge and understanding of a variety of insurances including Traditional Medicare, Medicare Advantage Plans, and Commercial Plans

Nice To Haves

BSN, MSN, LCSW, LPC, or LMFT preferred
Knowledge and experience with chemical dependency and mental health programs, situational evaluations, and crisis intervention preferred

Responsibilities

Conduct concurrent and extended-stay reviews using ASAM criteria and DSM-5 guidelines to determine medical necessity, appropriateness of care, continued stay, and discharge criteria
Collaborate with Admissions, Clinical Staff, Nursing, Medical Records, Business Office, and providers to address insurance issues and communicate patient information and benefits
Review patient records, treatment plans, and clinical status; communicate pertinent third-party payor requirements and acuity concerns to physicians and the treatment team
Perform clinical reviews with insurance case managers by telephone and electronically while maintaining positive working relationships with third-party payors
Maintain accurate and timely documentation in MIDAS and other Utilization Management records; run and interpret reports as needed
Prepare and submit timely appeals to third-party payors, working with the Business Office and treatment team to gather supporting documentation
Attend treatment team and AR/Denials meetings and maintain records in accordance with applicable policies, regulatory requirements, and accreditation standards