Utilization Review Specialist
|Title:||Utilization Review Specialist|
|Location:||1150 Red John Road, Daytona Beach, FL 32124|
Working Hours: 40 hrs week; Mon-Fri; some weekends may be required
A currently competent Utilization Review Specialist, who provides a professional review of clinical services and staff’s clinical activities via the client record to assure that client placement and service delivery complies with the UM standards of SMA Healthcare. The position primarily focuses on overseeing authorization expectations for third party payment of treatment services for clients who have private pay insurance carriers. The UR Specialist will assist in the review of client records for tracking and auditing purposes as well as other issues of compliance with SMA services standards, CARF requirements, state licensure, Medicaid and other quality improvement standards as assigned by the department supervisor.
- High School Diploma with a minimum of 8 years of work experience in utilization review/ management
- Bachelor’s degree in Human Services or a related field from an accredited university with a minimum of 2 years of related work experience
- Master’s degree from an accredited university with a minimum of 1 year of related work experience
- Registered Nurse with a degree in nursing from an accredited university with a minimum of 2 years of related work experience
Experience with American Society of Addictions Medicine Patient Placement Criteria is preferred. Experience with CARF, Medicaid, and Managed Care requirements is preferred.
- Must be knowledgeable and demonstrate competency in current best practices of behavioral health treatment and related services, especially as it relates to documenting the course of treatment and patient placement criteria in the client record.
- Depending on assignment must have knowledge of typical diagnoses, treatment services, and developmental issues for adolescents in general, delinquent adolescents, adults and pregnant/post partum women who are admitted to a mental health and/or substance abuse treatment setting.
- Demonstrates proficiency with assigned client populations in performing utilization reviews in records of clients with specific problems and needs.
- Knowledge of growth and development.
- Ability to assess age specific data.
- Ability to interpret age specific response to treatment.
- Knowledge of the treatment needs of adolescent mental health, substance abuse, co-occurring, ADD, ADHD, conduct, and oppositional defiant disorders.
- Knowledge of the treatment needs of adult mental health, substance abuse, and co-occurring diagnoses of affective disorders, anxiety disorders, PTSD, and antisocial personality disorder.
- Knowledge of the treatment needs of adult pregnant/post -partum women with mental health, substance abuse, and co-occurring diagnoses of affective disorders, anxiety disorders, PTSD, and antisocial personality disorder.
- Proficiency in working with telephone system and telephone etiquette.
- Proficiency in working with computer hardware and software, when assigned.
- Performs concurrent reviews as assigned by Clinical Compliance Director of client records in accordance with operating procedures of SMA UM Plan to certify appropriateness of admission and continued stay and discharge planning based on the criteria of the UM Plan.
- Performs retrospective reviews as assigned by Clinical Compliance Director of client records according to the operating procedures of the UM Plan to certify discharge appropriateness of discharge/referrals based on the criteria of the UM Plan.
- Writes and distributes to staff legible, informative, and understandable notices of non-compliance issues identified through reviews of client records with copies to their supervisors.
- Acts as an advisor to the staff and program supervisors through in-service trainings, individual meetings and written communications issues pertaining to the documentation expectations of insurance companies and other third party payors.
- Submits a monthly written and oral report to the Performance Improvement Council detailing the number and percentages of authorizations for each level of care. Reports on a monthly basis the type of documentation problems that are causing denial of payment for services provided.
- Submits a written annual summary report of monthly reports for each calendar year and presents orally to PIC upon request.
- As assigned, assists in the development of operating procedures and admission, continued stay, and discharge criteria for SMA's UM Plan with members of the PIC and/or the Clinical Compliance Director.
- Improves professional knowledge and skill base relevant to utilization management by attending seminars, trainings, and conferences and by reading current literature.
- Participates in required SMA in-service trainings to maintain employment.
- As assigned, assists in the maintenance of SMA's compliance with treatment and documentation requirements of funding sources, performance improvement, and accreditation activities.
- Acts as liaison between SMA staff and insurance companies, funding sources, or their managed care organizations when client’s health care is being managed under a managed care plan.
- When assigned or review requires it, coordinator is knowledgeable of up to date standards/criteria of ASAM PPC, Medicaid, a particular MCO, DCF, and CARF.
- Makes commitment to SMA’s mission and core values the SMA Way
- Abides by principles of EEO compliance and a workplace of dignity and respect.
- Works cooperatively in a group/team setting.
- Shows respect to others.
- Takes guidance and direction from supervisors.
- Arrives/Reports to work on time and ready to work.
EEO Employer W / M / Vet / Disabled