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Utilization Reviewer - Behavioral Health

Company: St. Vincent Charity Medical Center
Location: Cleveland
Posted on: September 24, 2022

Job Description:

The Utilization Reviewer coordinates utilization review to ensure reimbursement for facility services. She/he will evaluate medical records, negotiate and advocate for patient length of stay as well as level of care. The Utilization Reviewer will review patient care from the perspective of medical necessity, quality of care, appropriateness of decision-making, place of service, and length of hospital stay, as well as all other duties as assigned.PRIMARY RESPONSIBILITIES:Responsible for initial pre-certification & utilization review for incoming behavioral health patients' insurances, unless completed by intake on admission. Assists in recommending the most appropriate treatment for the patient as an interdisciplinary team member. Facilitates a timely movement for the patient through the treatment continuum. Communicates effectively with physicians, team members, payers, administrators and patients about treatment issues. Coordinates care to achieve quality/cost-effective outcomes. Collect data on patients for both utilization review and quality assessment. Gathers demographic and clinical information on prospective, concurrent, and retrospective in-patient admissions and out-patient treatment (when appropriate). Monitors and addresses denials of payers. Informs physicians/staff about payment denials Keeps records of denials and works with the billing department in regards too patient accounts. Share utilization data with insurance companies to complete insurance certification. Assist in the denials and appeals process. Enters insurance verification, benefits notes and numbers of covered days into computer systems. Participates in performance improvement. Collects and prepares statistical reports. Formulates a plan of care in collaboration with interdisciplinary team. Regular data collection and reporting. Serve as a resource to direct care staff in the interpretation of clinical service descriptions. Consults with relevant members of the interdisciplinary team such as Physician, Nursing, Occupational/Recreational Therapy and Chemical Dependency Counseling to assist in developing an interdisciplinary treatment plan. Establishes priorities for care, in collaboration with treatment team to ensure patient needs are met in an appropriate timeframe to promote good outcomes and increase patient satisfaction. Identifies expected patient care outcomes and the time frame for their achievement and/or review in collaboration with treatment team. Attends treatment team and collaborates with other members of team regarding patient's care and progress.KNOWLEDGE, SKILLS AND EXPERIENCE REQUIREMENTS:Bachelor's Degree in Nursing, Social Work, or related field of studyMust have one of the following licenses: LSW, LISW, LISW-S, RN, LPNExperience with a psychiatric mental health or chemically dependent population requiredPrevious experience in Behavioral Health Utilization ManagementSuperior customer service, communication and organizational skillsDemonstrated PC skills (MS Office, Word, Excel, Outlook)Able to effectively prioritize, facilitate and complete assignments in an accurate and timely mannerMust be able to perform the essential functions of the position with or without reasonable accommodationPlease apply via job link below:

Location: Canton-Cuyahoga Corporations Intake/AccessSchedule: Part Time, Rotating Shifts, varied

Keywords: St. Vincent Charity Medical Center, Cleveland , Utilization Reviewer - Behavioral Health, Healthcare , Cleveland, Ohio

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