Utilization Review Coordinator

Job Description

Job Description

Job Summary:

The primary responsibility of this position is to implement the organization’s Utilization Review (UR) process so as to ensure appropriate usage of available resources and to optimize reimbursement for services rendered in accordance with patient need. The UR coordinator monitors the client population on a daily basis and regularly checks documentation for compliance with current UR best practices. The coordinator serves as the primary liaison with payers in matters related to utilization, takes a lead role in organizing and conducting UR and provides regular reports to facilitate decision making by senior management. The coordinator also assists in other key administrative functions such as handling admissions enquiries, orienting new patients and families, verification of benefits, and implementation of the organization’s performance management and improvement process.

Duties and Responsibilities:

• Implement the UR process in accordance with organizational policies and procedures.
• Gather information and contact insurance case managers with accurate reports on client’s medical information and the level of engagement in treatment.
• Ensure UR function is performed in compliance with P&P, certification standards, and state/Federal statues and/or regulations.
• Maintain a mature and professional manner during phone contacts with payers and in dealing with clients, staff, visitors, and the public.
• Maintain accurate account of the level of care granted by the insurance companies.
• Maintain the daily information, on the client, is accurate and held to strict confidentiality and HIPPA regulations.
• Participate in the morning staffing meetings.
• Provide adequate and appropriate services consistent with best practice and industry standards.
• Adhere to rules and regulations of Department State Health Services, CARF and all Facility standards. To include at a minimum the following:
  1. Facility policies and procedures
  2. Client’s rights, including unique needs of the persons served
  3. Client grievance procedures
  4. Confidentiality of client-identifying information (42 C.F.R. pt. 2; HIPAA)
  5. Standards of conduct
  6. Emergency and evacuation procedures (incident reporting)
  7. Exemplary Customer Service
  8. Work with a diverse population of clients/staff

Competencies:

• Strong analytical and problem-solving skills.
• Strong oral and written communication skills
• Strong organization and time management skills
• Occasionally exposed to various and unpredictable situations (i.e., client behavior)
• Ability to answer and transfer a multiline telephone system
• Ability to work independently and proceed with objectives without supervision
• Ability to multi-task

Education/Experience/Qualification:

• Bachelor's degree required
• 2+ years of Clinical Behavioral/Mental Health Experience.
• Familiar with standard concepts, practices, and procedures for all ASAM outpatient levels of care
• Knowledge of all continuums of care, including admission assessment and continued stay criteria
• Excellent verbal and written communication skills