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Utilization Reviewer - PRN

Job Description
Organization: 
Behavioral Healthcare, Inc
Organization Type: 
501(c)(3)
Job Location: 
Central Mountains
Type of Job: 
Full-time
Job Category: 
Administrative | Health & Mental Health
Job Description: 

BHI is seeking a licensed behavioral health professional to join our 24/7 utilization management team working PRN to cover shifts as needed.

Working as part of an interdisciplinary team, the Utilization Reviewer is responsible for clinical review and authorization or recommendation for denial of services to members regarding the full continuum of care, including but not limited to psychiatric inpatient, sub-acute and specialty services. The Utilization Reviewer may participate in complex case reviews with multidisciplinary teams, disposition planning, coordination of benefits and care among providers and systems. This position is expected to consistently apply medical necessity criteria and decision support software when making utilization determinations. Provide documentation and recommendations to the Chief Medical Officer or appeal psychiatrist to determine appropriate levels of care.  Applying and completing the processes for authorization letters and or notice of actions and appeal letters when appropriate.  

Areas of Responsibility

JOB DUTIES/ACCOUNTABILITIES

85%

  1. Utilization  Review
  • Review and make decisions (approve, recommend denial, or continued stay) for members in higher levels of care than normal outpatient services (e.g. acute, sub-acute high intensity, sub-acute low   intensity, day treatment, intensive outpatient, in-home, residential, etc.) based on the medical and/or clinical necessity, amount and scope, appropriateness, efficacy and/or efficiency of behavioral health services, procedures and/or settings. 
  • Implement UM processes and adjust as needed ensuring compliance with all State and National Commission on Quality Assurance (NCQA) accreditation standards.
  • Overseeing complex cases: engaging systems, problem solving, in the best interest of the member and the organization .  
  • Involved in complex cases, attend internal meetings, assist in identifying provider relations issues, and provide customer care.
  • Attend community meetings for members and provider trainings to providers as needed
  • Coordinate all new requests for levels of care
  • Maintain and monitor a case load of members within the levels of care

 

10%

  2. Quality Improvement

  • May serve as a member of quality assurance committee
  • Assist quality improvement with auditing and training
  • Assist in matters related to compliance in the areas of NCQA accreditation, the company's Medicaid contract, and External Quality Review Organization (EQRO), as requested

 

5%

 3. Coordinate appeals with independent appeal review, ensuring that all Notice of Action time frames are met

Requirements/Qualifications
  • 4 Year Degree
  • 2+ years of direct patient care
How To Apply

For more information, or to apply now, you must go to the website below. Please DO NOT email your resume to us as we only accept applications through our website.

https://www.applicantpro.com/j/439947-40435

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