Monitor utilization of services and optimize reimbursement for the facility while maximizing use of the patient’s provider benefits for their needs. This role is an onsite telephonic liaison between treatment team and Insurance Companies. To provide clinical justification for continued inpatient treatment.

Essential Functions

• Secure authorizations with insurance companies for inpatient treatment and continue to obtain authorizations for duration of patient stay, providing consultation and guidance regarding admissions and patient length of stay to a variety of payers.
• Evaluate the utilization program for compliance with regulations, policies and procedures.
• Review clinical documentation from denied stays against criteria to determine if documentation is adequate for requested treatment.
• Participate in daily interdisciplinary rounds, and reviews case with clinicians as needed.
• Participates in the development of discharge planning goals and estimated lengths of stay to ensure appropriate care.
• Develops collaborative relationships with payers, including telephone reviews, appeals, and participation in on-site visits.
• Certifies all continued stays according to payer requirements and provides data to appropriate department, maintaining open communication with the payer to ensure continued coverage of the patient’s hospitalization.
• Maintains regular communication with the Program Director & RN Manager, for the purpose of coordinating admissions and discharges.
• Maintains organized records of third party communications.
• The employee maintains communication with patient financial services department when indicated.
• The employee consults with supervisor on problematic cases.
• Provides continuity of coverage in emergency situations.
• Provide staff management to including hiring, development, training, performance management and communication to ensure effective and efficient department operation.

Experience

• 4 year(s): A minimum of four (4) years direct clinical experience in a psychiatric or mental health treatment setting. Experience in patient assessment, treatment planning, and communication with external review organizations or comparable entity.

• One (1) year of experience in managing a related function.

Education

• Bachelors or better in Social Work or related field
• Bachelors or better in Nursing/Healthcare or related field

Licenses & Certifications

• Reg Nurse
• Lic Clin Social Wkr

Skills

• Planning & Organizing
• Customer Focus
• Communication

Behaviors

• Functional Expert: Considered a thought leader on a subject
• Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well

Motivations

• Self-Starter: Inspired to perform without outside help