Posted in Nurse 30+ days ago.
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Location: Kokomo, Indiana
The Utilization Review Analyst position is located in Kokomo, IN
• The Utilization Review Analyst recognizes and commits to critical importance of customer satisfaction (both internal and external customers).
• Develops and implements outpatient pre/re-certification processes for commercial insurance coverage of outpatient treatment services
• Develops and implements outpatient Medicaid prior authorization processes.
• Ensures effective implementation of outpatient pre/re- certification processes for treatment services and Medicaid prior authorization processes through monitoring and continuous improvement
• Interfaces between individual staff psychiatrists and therapists/clinicians and payer representatives to resolve problems in regard to insurance coverage for patients. Ensure appeal process to be utilized and that cases are deemed appropriate to appeal
• Gathers, analyzes, and presents utilization data to BCS/Gallahue management for outpatient mental health and chemical dependency services. Systematically identify and analyzes patterns of over/under utilization and inefficient use of resources
• Identification of quality of care issues through monitoring of outpatient pre/re-certification processes for treatment services, Medicaid proper authorization processes
• In conjunction with BCS/Gallahue MIS, coordinator recommends and assists in the implementation of MIS solutions to improving the efficiency and effectiveness of all BCS/Gallahue per/re-certification, prior authorization, and enrollment processes
• Ensure compliance with State, Federal, and other regulatory requirements related to utilization review
• Complies with all applicable Behavioral Care Services policies and procedures
Three (3) to five (5) years of experience in mental health/chemical dependency. Experience in Behavioral Health Utilization Review preferred
This position requires a Bachelor’s degree in social work, psychology, sociology or related field. Bachelor’s degree in Nursing with Registered Nurse license by the Indiana Professional Licensing Agency preferred
• Strong communication skills
• Ability to work independently and in a highly organized manner
• Ability to work in a team environment
• Knowledge and understanding systems of behavioral health utilization review
• Strong computer skills
Outpatient Utilization Review, Behavioral health, Mental Health
Ranked among the nation's most integrated healthcare systems, Community Health Network is Central Indiana's leader in providing convenient access to exceptional healthcare services, where and when patients need them – in hospitals, health pavilions and doctor's offices, as well as workplaces, schools and homes. Exceptional care, simply delivered.
Community is a non-profit health system that is deeply committed to the communities we serve with more than 200 sites of care and affiliates throughout Central Indiana. Guided by our PRIIDE Values – Patients First, Relationships, Integrity, Innovation, Dedication and Excellence – our team of caregivers is committed to providing an exceptional experience with every life we touch