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