Utilization review coordinator job description

Overview: *
All positions are located in Fresno/Clovis CA
*

Our
Community Behavioral Health Center
is licensed to 73 bed, carries an average daily census of 69 patients, and has an average length of stay of 5-6 days. CBHC is the largest psychiatric care facility in the area providing 24-hour adult, inpatient psychiatric care. We work to ensure optimal mental health for our patients, their families and the community at large through education and treatment. We care for adults in a safe and therapeutic environment. If you are seeking a career that matches your passion for helping people, then continue reading below! Responsibilities: Responsible for various aspects of utilization management to ensure that care is rendered in accordance with intensity of service and severity of illness standards at all times during the acute stay, utilizing InterQual system as a guideline. Works collaboratively with the Case Management team, other departments, and physicians to facilitate efficient and appropriate management of all cases.


Insight into the role

• Coordinate of care by monitoring the patient care plan with a strong knowledge and appropriate use of community resources to ensure safe discharge plans.
• Collaborates on development of appropriate discharge plan based on assessment, physician and multi-disciplinary team input.
• Will work in a collaborative team environment with physicians and medical staff.
• Responsible for analysis and reporting of utilization data.
• Provides assistance and education to staff and physicians with questions and problems involving patient treatment plan, medical necessity and appropriate utilization management.

Qualifications:
Education

• Associate's Degree in Nursing required
• Bachelor's Degree in Nursing preferred


Experience

•
2
years of experience as a Registered Nurse with experience in discharge planning, case management or utilization management required
or

•
5
years of LVN experience in discharge planning, case management
or
utilization management required


Licenses and Certifications

• RN - Current State of California Registered Nurse license required
• BLS - Current Basic Life Support (BLS) for Healthcare Providers by American Heart Association (AHA) required


Preferred:

• ACM - Accreditation in Case Management preferred
• CCM - Certified Case Management preferred

Please note: Per the CDPH order, all healthcare workers are required to be vaccinated for COVID-19 or have an approved exemption and test regularly.

Please note: If any bonuses are noted, they are only applicable to external hires.

Candidates must also meet current bonus requirements to be eligible.

Primary Job Function: Behavioral Health

ID**: 25022

Your career starts now. We're looking for the next generation of health care leaders.

At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com .

**Responsibilities:**

Under the direction of the Supervisor, Appeals and Grievances, the Behavior Health UM Reviewer (BHR) is responsible for completing medical necessity reviews.

+ Using clinical knowledge and experience, the clinician reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review.

+ It is within the Behavior Health UM Reviewer's discretion to retain requests for additional information and/or request clarification.

+ The BHR will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases to integrated care management as needed.

+ The BHR will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when indicated.

+ BHR's are responsible to ensure that treatment delivered is appropriately utilized and meets the Member's needs in the least restrictive, least intrusive manner possible.

+ The BHR will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit's business and uses clinical judgment in their application.

**Education/ Experience:**

+ Master's Degree.

+ Registered Nurse.

+ Registered Nurse graduate from an accredited institution with a Bachelor's Degree.

+ Master's Degree preferred OR LSW, LPC, LMFT licensure with a Master's Degree.

+ Minimum 3 years' experience in a related clinical setting. Managed Care and Utilization Management experience required.

**Other Skills:**

+ Behavioral Health Management experience required.

EOE Minorities/Females/Protected Veterans/Disabled

The MENTOR Network provides services for adults with intellectual and developmental disabilities and medically complex needs.
Utilization Review Coordinator

Do you have experience in Title XIX program rules, regulations, and limitations, and want to join a company that positively impacts the lives of the many individuals it serves? In the Program Administration Utilization Review Coordinator role, you will contribute to the company's commitment to serve others by ensuring adherence to Title XIX waiver regulations/limitations and managed care authorizations.

* Assist in the collection of service provisions and current service information for upcoming team meetings or service change review meetings
* Conduct service authorization reviews and receive confirmation from program supervisor(s) for approval of all pending and final service authorizations
* Provide analysis to assure that service delivery corresponds with service support hours and units, staff hours and assignments, payroll hours and billing tickets, etc.
* Effectively track/assure that current and approved Individual Service Plan(s) appropriately correspond and match areas of support services and service delivery documentation records
* Maintain incoming service delivery documentation and corresponding billing tickets/pre-invoice received for processing in the regional office
* Establish and monitor the regional office/storage filing systems to assure information is organized, complete, and retrievable
* Actively engage in on-going communication with AR coordinators and/or AR accountants to facilitate timely resolution to outstanding issues and items pending payment for services provided to customers
* Assist in communication with Interdisciplinary Planning Teams to address areas of identified errors, corrections, or needed services related to billing units and over/under utilization areas
* Assure and maintain functional knowledge base and materials related to current and new funding rules and contracts
* Assist Utilization Specialist in recruiting, screening, and evaluation of personnel
* Make recommendations for hire; conduct initial/on-going in-service, certification, and training; oversee/evaluate work

Qualifications:

* High School diploma or equivalent
* Minimum 1 year of experience working with Title XIX waiver program rules, regulations, and limitations
* Ability to manage/prioritize multiple tasks
* Effective communication skills and well-developed problem-solving skills
* Exceptional attention to detail and a commitment to quality in everything you do
* Foster culture of continuous improvement

Why Join Us?

* Full compensation/benefits package for employees working 30+ hours/week
* 401(k) with company match
* Paid time off and holiday pay
* Complex work adding value to the organization's mission alongside a great team of coworkers
* Enjoy job security with nationwide career development and advancement opportunities

We have meaningful work for you - come join our team - apply today!

The MENTOR Network is becoming Sevita. Sevita is a leading provider of home and community-based specialized health care. We believe that everyone deserves to live a full, more independent life. We provide people with quality services and individualized supports that lead to growth and independence, regardless of the physical, intellectual, or behavioral challenges they face. We've made this our mission for more than 50 years. And today, our 40,000 team members continue to innovate and enhance care for the 50,000 individuals we serve.

Equal Opportunity Employer, including disability/vets

Other details

* Job Family Program Administration
* Job Function Program Support
* Pay Type Hourly
* DBA Sevita

Apply Now

* Austin, TX, USA