Utilization Review Specialist
Company: Vermilion Behavioral Health
Location: Lafayette
Posted on: January 26, 2023
Job Description:
ESSENTIAL FUNCTIONS:
- 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.
- 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.
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:
- Associate's degree in nursing (LPN or RN) required. Bachelor's
or Master's degree in social work, behavioral or mental health,
nursing or other related health field preferred.
- Two or more years' experience with the population of the
facility and previous experience -in utilization management
preferred. LICENSES/DESIGNATIONS/CERTIFICATIONS:
- Current licensure as an LPN or RN 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.
Keywords: Vermilion Behavioral Health, Lafayette , Utilization Review Specialist, Other , Lafayette, Louisiana
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