Behavioral Health Utilization Management Coordinator (Eastside)

JOB PURPOSE: The purpose of this position is to ensure that admitted patients have the appropriate level of care, patient status, authorization status, plan of care and meet medical necessity for the behavioral health services. This role monitors that the patient is progressing in their plan of care and meet medical necessity for continued stay. This role ensure that patient’s payor has the clinical information with which to authorize the behavioral health service and continued stay service to include covered days and associated services.

KEY RESPONSIBILITIES:
1. Ensure precertifications / authorizations are obtained for behavioral health procedures
2. Liaise with Care Manager / Social Worker at the bedside to obtain information from physicians as needed
3. Ensure that status & level of care determination are accurate upon admission
4. Perform admission, concurrent and retrospective reviews as required
5. Obtain Medicaid precertifications for inpatient admits and ED observation procedures as required.
6. Facilitate effective communication with members of the treatment team
7. Follow Medicare guidelines regarding utilization review.
8. Follow up with insurers for authorization& Labor, Care & Delivery
9. Access Medicaid Web Portal to submit clinical information
10. Identify, document and report quality, cost and risk variance related to patient’s plan of care
11. Facilitate per to peer appeals and secondary review process when necessary

Requirements

MINIMUM EDUCATION REQUIRED: Degree from an accredited nursing school, B.A/ B.S or LMSW/LCSW

MINIMUM EXPERIENCE REQUIRED: Two (2) years of experience in an acute, post-acute, managed care, psychiatric, or revenue cycle.

MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW: Current unrestricted registered nurse (RN) license or LMSW/LCSW, in the state of Georgia.

Preferred: Case Management Certification (CCM) or American Case Management Association (ACMA) certification. Master’s degree and three (3) years of Utilization Review or Care Management experience.

ADDITIONAL QUALIFICATIONS:
Previous experience with InterQual and/or MCG guidelines
Previous experience in Utilization Management and/or Appeals
Previous Epic experience or Meditech/MIDAS experience
Previous experience in prior authorization process

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