Conducts utilization review on all assigned cases and ensures authorizations are completed timely with all dates of service reviewed.
Documents all contact with payers and outcomes of reviews to ensure compliance. Participate in department in-service/training programs.
Provides consultation and guidance regarding admissions and continued stay criteria for a variety of payors.
Reviews clinical documentation from denied stays against criteria to determine if documentation is adequate for requested treatment.
Maintains current knowledge of applicable regulations and regulatory update in the behavioral health field.
Responsible for abundant data entry.
Validates that the request for authorization is complete or requests additional data from requesting physician, if necessary.
Follow all regulatory policies and procedures, privacy and security standards in accordance with government agencies including HIPAA requirements.
Provides accurate and complete clinical information to payors based on synthesized documentation in the medical record.
Completes retrospective reviews on assigned cases when updated insurance information becomes available subsequent to admission or after discharge.
Communicates discharges timely to payors for all assigned cases.
Notifies attending physician, direct supervisor and unit staff of in-house denial decisions.
Collaborates with the treatment team regarding quality and completeness of documentation and serves as a resource for nursing and clinical staff on documentation requirements.
Communicates with the responsible staff when clinical documentation is unclear, incomplete, unprofessional, or not relevant to the Master Treatment Plan goals and/or fails to supports medical necessity criteria for continued stay at the current level of care.
Participates in routine weekly chart auditing as assigned to ensure ongoing compliance with regulatory requirements.
Discusses utilization review decisions with patients and/or family members as appropriate.
Coordinates with clinical staff regarding progress of discharge planning for patients whose care has been denied.
Effectively manages time by scheduling concurrent telephonic reviews in advance when possible to efficiently manage caseload and work hours.
Attending clinical staff meetings to obtain clinical information pertinent to clinical reviews.
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Job ID: UTILI055339
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