Utilization Review Coordinator

Key Functions

1. Perform both internal and external record reviews as part of daily department operations.

• Cooperates with Admissions to complete certifications as needed and documents outcome in certification record.
• Performs concurrent utilization review with insurance companies and relevant payers, documenting outcome of same in the certification record.
• Obtains and documents authorization for services not covered under per diems and communicates directly to physicians/clinician/patients/guarantors.
• Maintains an appropriate and ethical performance of reviews, both internal and external.

2. Develop and maintain professional relationships with treatment team members to enhance the role of Utilization Management within the organization.

• Communicates to appropriate members of the treatment team the status of the cases assigned with mandatory reporting to the physician or team designee.
• Communicates need for Peer Reviews between physician and payers, facilitating as needed; completes documentation.
• Attends team/staff meetings per program scheduling, as clinically indicated.

3. Assist in preparedness for surveys by regulatory agencies and payers.

• Audits/reviews charts-depth and intensity to be determined by data collection reports.

Education: Required: Bachelor's degree in a clinical discipline, (i.e. Social Work, Psychology, Nursing, or healthcare field.) Equivalent years of mental health experience may be substituted for Bachelor's degree.

Experience:

• Three years' experience in a health care field.
• Minimum of one year full time experience performing insurance reviews, either pre-certification and/or concurrent reviews.
• Proficient in the use of computers, calculators, phones, fax machines, and copy machines.
• Basic knowledge of Microsoft Office, health insurance/collection regulations, team concepts/performance improvement, human behavior and psychopathology. Basic knowledge of managed care concepts, social/family systems, and treatment modalities.
• Knowledge of DSM V