Utilization Review Manager- Behavioral Health

Utilization Review Manager- Behavioral Health | Raleigh Oaks Behavioral Health | Garner, North Carolina

About the Job:

The Utilization Management Manager is responsible for the overall management of the UM department by leading and facilitating review of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria. Directs and manages the day-to-day operations and supervision of staff to obtain coverage for patients, monitors the progress of all UR cases and insurance appeals, problem solves when necessary and mitigates all issues with utilization. Monitors utilization of services and optimizes reimbursement for the facility while maximizing use of the patient’s provider benefits for their needs.

Roles and Responsibilities:

· Assigns all patients to Utilization Review staff and supervises staff to ensure staff are completing insurance verifications on time and compliant with regulatory standards and requirements.

· Ensures staff are competent to review medical records of clients for appropriateness of level of care at admission and at intervals determined by documentation in medical record and to communicate patient insurance status and needs with all disciplines.

· Leads a team of highly engaged members thru hiring, orienting, performance assessment and management, motivating, training, scheduling, and coaching to meet department goals and ensure effective and efficient department operation.

· Works closely with Admissions Department to ensure patient information is accurate and pre-certification is complete. Reviews application for patient admission and approves admission or refers case to utilization review committee for review and course of action when case fails to meet admission standards.

· Manages any discrepancies regarding stated benefit information and insurance verification, need for updated benefits or follow-up on a problem with a pre-certification from admissions.

· Appeals all denials ensuring accuracy of information and effective coordination of correspondence.

· Analyzes patient records to determine appropriateness of admission, treatment, and length of stay to comply with government and insurance company reimbursement policies. Ensures charting deficiencies are minimized and corrected timely by responsible staff. Identifies and forwards charts for review based on outlying data to the Medical Director.

· Analyzes insurance, governmental and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.

· Compares patient’s medical records to established criteria and confers with medical, clinical, nursing, and other professional staff to determine appropriateness of treatment and length of stay. Communicates and coordinates information with business office to recognize and resolve potential payment issues.

· Conducts and oversees concurrent and retrospective reviews for all patients. Assists review committee in planning and holding mandated quality assurance reviews.

· Acts as a liaison between Medicaid reviewers and the staff completing required paperwork to facilitate the Utilization Review process.

· Graduation from an accredited school of nursing OR a Bachelor's degree in social work, behavioral or mental health, or other related health field required. Master's Degree in same field preferred.

· Four or more year's clinical experience with the population of the facility required.

· Two or more years’ experience in medical/psychiatric utilization management required.

Minimum of one year supervisory experience in clinical setting/utilization required.

· Comprehensive understanding of the admission, concurrent, continued stay, and retrospective reviews using the established hospital criteria.

· Ability to communicate professionally and effectively with multidisciplinary team members, managed care organizations and business office, providing needed information in a logical, concise manner using technical language that accurately describes patient’s condition.

· Current licensure as an LPN or RN or current clinical professional license or certification, as required, within the state where the facility provides services.

· CPR and de-escalation certification required (training available upon hire and offered by facility).

Why Raleigh Oaks Behavioral Health?Raleigh Oaks Behavioral Health offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications. Qualified candidates should apply by submitting a resume. Raleigh Oaks Behavioral Health is an EOE.

Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.