The Utilization Review Case Manager is responsible for working with insurance companies and managed care systems for the authorization, concurrent and retrospective review of inpatient admissions and services. This position will obtain authorization for each admitted patient. Review and monitor each step of the authorization process to proactively identify potential problems to help patients access the full range of their benefits through the utilization review process.
- Conducts admission reviews.
- Conducts concurrent and extended stay reviews.
- Prepares and submits appeals to third party payors.
- Maintains appropriate records of the Utilization Review Department.
- Performs related duties, as requested.
- Upholds the Organization's ethics and customer service standards.
*This position is on-site and NOT a remote position.*
- Education: Clinical degree such as nursing, social work, psychology, health information management or other related healthcare field is preferred or related experience.
- Required Licenses: None
- Experience: Two years clinical experience in a facility with medical terminology and in criteria for acute psychiatric care or combination of education and experience preferred.
- Knowledge, Skills & Abilities:
- Must have basic PC skills that include a combination of working in a Windows Operating System and Microsoft Outlook, Word and Excel.
- Must have excellent communication skills and be a good listener with a pleasant demeanor that encourages and engages others.
- Flexibility; attention to detail; able to multi-task, prioritize with strong time management skills; responsiveness to deadlines, assertiveness, persistence, and persuasiveness; able to work with minimal direction or supervision.
- Knowledge of managed care environment; ability to apply and interpret admission and continued stay criteria; understanding of admission and discharge function; familiarity with medical terminology, diagnostic terms and treatment modalities.
- Knowledge of medical record keeping; strong interpersonal, organizational, evaluative, and time management skills; policy interpretation skills; familiarity with applicable standards and regulations.
- Ability to comprehend psychiatric evaluations, consults, lab results, etc.
- Screening: Must successfully pass background check, drug screen, physical and be able to provide positive employment references.
- Physical Demands: With or without reasonable accommodations, must be able to stoop, kneel, crouch, reach, stand for sustained period of time, walk, pull, lift, raise and move objects from position to position (up to 50 lbs), finger grasp; feel sizes, shapes, temperatures, and textures; express or exchange ideas orally and potentially loudly, accurately, or quickly; visually detect, determine, perceive, identify, recognize, judge, observe, inspect, assess; perceive the nature of sound with or without correction; perform repetitive motions of the wrist, hands, or fingers.
This job description is not intended to be all-inclusive. Employee may perform other related duties to meet the ongoing needs of the hospital.
Full-time employees are eligible for medical, dental, vision, company paid disability, 401(k) and a generous amount of paid time off.
