Utilization Review Specialist
Vantage Point Behavioral HealthOur take on this role
About this role
Monitor service use for patients at a behavioral health hospital to optimize reimbursement, and coordinate reimbursement communication between managed care organizations and clinical staff. This is a full-time role in Fayetteville, Arkansas.
What could you bring from clinical work?
- Nurses and PTs: Your experience documenting clinical needs and skilled-service necessity could help with reviewing medical necessity and services provided.
- Social workers: If you've documented psychiatric care needs, that experience may help you prepare appeals for denied admissions or continued stays.
- OTs and SLPs: Experience documenting treatment needs and explaining medical necessity could help you train staff on charting requirements and medical necessity updates.
Full job description from Vantage Point Behavioral Health
Overview
Vantage Point Behavioral Health Hospital is seeking a Full Time Utilization Review Specialist at our Fayetteville, AR location.
PURPOSE STATEMENT:
Proactively monitor utilization of services for patients to optimize reimbursement for the facility.
- Act as liaison between managed care organizations and the facility professional clinical staff.
- Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
Responsibilities
ESSENTIAL FUNCTIONS:
- Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
- Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
- Conduct quality reviews for medical necessity and services provided.
- Facilitate peer review calls between facility and external organizations.
- Initiate and complete the formal appeal process for denied admissions or continued stay.
- Assist the admissions department with pre-certifications of care.
- Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.
OTHER FUNCTIONS:
- Perform other functions and tasks as assigned.
Qualifications
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:
- Required Education: High school diploma or equivalent.
- Preferred Education: Associate's, Bachelor's, or Master’s degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.
- Experience: Clinical experience is required, or two or more years' experience working with the facility's population. Previous experience in utilization management is preferred
LICENSES/DESIGNATIONS/CERTIFICATIONS:
- Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.
- CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.
- First aid may be required based on state or facility requirements.
ADDITIONAL REGULATORY REQUIREMENTS:
While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances (e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.
We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.
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