POSITION TITLE: Utilization Review Clinician
REPORTS TO (TITLE): Director of Utilization Review
DESCRIPTION OF POSITION:
Work as a member of a multi-disciplinary treatment team reviewing patient care and treatment options for both inpatient and outpatient services. Proactively monitor and optimize reimbursement for external reviewers/third party payers.
KEY RESPONSIBILITIES:
- Conduct admission reviews.
- Conduct concurrent and extended stay reviews.
- Prepare and submit appeals to third party payers.
- Maintain appropriate records of the Utilization Review Department.
- Provide staff in-service training and education.
Education/Licensure:
- Current license as an LCSW, ASW, MFT, LMFT, RN, LPT, LVN or LPC.
- Preferred: Master’s degree in Social Work, Behavioral Science, or related field.
- Current CPR certification.
- Current NCI equivalent as approved by the Chief Nursing Officer (or obtained within the first 30 days of hire).
Knowledge and Experience:
- Demonstrated knowledge of health care service delivery systems and third party reimbursement.
- Two or more years’ experience working in a managed care environment.
- Ability to apply and interpret admission and continued stay criteria.
- Strong understanding of admission and discharge function.
- Familiarity with medical terminology, diagnostic terms and treatment modalities.
- Knowledge of medical record keeping requirements.
- Ability to comprehend psychiatric evaluations, consults, and lab results.
Skills and Abilities:
- Maintains confidentiality of patients at all times.
- Ability to cope well with stress and have a strong sense of compassion.
- Sensitivity to and willingness to interact with persons of various social, cultural, economic and educational backgrounds.
- Proficiency with software and/or equipment (Microsoft Office applications including Outlook, Word, Excel and PowerPoint).
- Strong organizational skills with ability to prioritize projects, work independently, manage multiple tasks, and meet deadlines.
- Strong written and verbal communication skills.
- Strong interpersonal skills; ability to work with people from a variety of backgrounds and educational levels.
- Ability to work independently and as part of a team.
- Good judgment, problem solving and decision-making skills.
- Demonstrated commitment to working collaboratively as well as possessing the skills to lead, influence, and motivate others.
- Ability to work in a fast-paced, expanding organization.
Physical Requirements:
While performing the duties of this job, this position is frequently required to do the following:
- Use standard office equipment and access, input, and retrieve information from a computer; use computer keyboard with manual and finger dexterity and wrist-finger speed sufficient to perform repetitive actions efficiently for extended periods of time.
- Communicate effectively in person or via telephone in a manner which can be understood by those with whom the person is speaking, including a diverse population.
- Give and follow verbal and written instructions with attention to detail and accuracy.
- Perform complex mental functions and basic arithmetic functions; interpret complex laws, regulations, and policies; collect, interpret, and/or analyze complex data and information.
- Vision: see details of objects at close range.
- Coordinate multiple tasks simultaneously.
- Reach forward, up, down, and to the side.
- Sit or stand for minimum periods of one hour at a time and come and go from the work area repeatedly throughout the day.
- Lift up to five (5) pounds.
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