Position Summary:
Communicates with third party payers regarding partial hospitalization and continued stay certification, and the retrospective appeals process. Essential Functions and Responsibilities:
Establishes a means of communicating and collaborating with physicians, other team members, the client's payors, and administrators. Work collaboratively with staff members from the disciplines and areas involved in the clients' care. Communicates with other members of the health care team regarding client needs, plan, and response to care/treatment.
Participates in variance analysis and presentation of cost/quality data to appropriate internal health care providers and organizational leadership.
Maintains a working knowledge of the requirements of payors. Maintains responsibility and accountability for the communication of clinical information required by the payor during the episode of hospital care, including pre- certification and continued stay authorization.
Educates health team colleagues about utilization review, including role responsibilities tools, and methodologies.
Obtains third party payer certification for inpatient and partial hospitalization and continued stay as required.
Maintains current knowledge of hospital billing processes and participates in the resolution of retrospective billing issues including appeals, PACER authorization, DRG validation and third party payer certification.
Applies readmission quality screens during concurrent and retrospective case review and reviews cases, which do not meet screening criteria to Medical Director of Utilization Management.
Maintains accurate complete documentation of all setting reviews, retrospective appeals and readmission/surgical review activity referrals.
Maintains open channels of communication between among all Access Center participants including Patient Registration, Insurance Verification, Patient Accounting, and Pre-Admission Testing.
Responsible for maintaining confidentiality of all information obtained while participating in Utilization Management Access Center activities.
Participates in Utilization Management department activities and committees as assigned to improve patient access systems and processes.
Performs other duties as required or requested
Qualifications:
Required:
Associate degree in nursing, medical records or behavioral health care field
2 years recent experience doing third party payor certification or working in behavioral health care field
Preferred:
Bachelor's degree in nursing, medical records or behavioral health care field
Knowledge of care delivery systems across the continuum of care including, but not limited to, trends and issues in care reimbursement, scope of alternate site care, and available community resources
