Posted in Health Care 30+ days ago.
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Location: Littleton, Colorado
Lead and conduct the utilization review and transitional case management for all clients admitted to the Acute Treatment Unit and Crisis Stabilization Unit; Ensure admission and continued stay criteria have been met and service authorization is obtained.
Duties and Responsibilities:
• Review pre-authorization requests and clinical information for medical necessity; referring to medical provider if necessary
• Conduct concurrent reviews, inpatient extensions of care, discharge planning and retrospective reviews
• Maintain accurate recordkeeping and prompt communication with all individuals involved with the approval of service and payment, including the treatment team and billing department
• Manage all UM records and processes
• Collaborate with the Revenue Cycle department to understand billing and coding practices and processes for reimbursement and payment of services rendered
• Monitor referral patterns and make recommendations on strategies to contain costs, improve access and insure quality care
• Use effective relationship management, coordination of services, resource management, education, client advocacy, and related interventions to: promote improved quality of care and/or life, promote cost-effective behavioral health outcomes, prevent hospitalization when possible and appropriate, promote decreased lengths of hospital stays when appropriate, provide continuity of care, assure appropriate levels of care are received by clients
• Partner in coordinating transitions of care as it relates to discharge of clients from ATU or CSU. Provide appropriate consultation and referral to case management staff
• Collaborate as a member of an interdisciplinary team. Contribute actively and effectively with the medical provider, case manager and other members of the healthcare team to ensure appropriate plans of care, along with appropriateness of services being rendered
• Function in an integrated role with other internal employees and external community partners to ensure teamwork, best practices and continuity of care for clients across the Network
• Establish effective rapport with other employees, professional support staff, clients and families, and others involved in providing coordinated care for clients
• Demonstrate customer service focus, communication and professionalism with co-workers, clients and outside agency personnel in order to provide high quality care and enhance community relationships
• Complete all paperwork accurately, legibly and within established timelines.
• Follow all AllHealth Network policies and procedures
• Complete all required trainings as listed in Relias Learning (both online training and face-to-face training) within required timelines
• Perform other duties as required within the scope of the position and the experience, education and ability of the employee.
Key Technical Skills and Knowledge:
• Master’s degree in human services field or BSN/RN.
• Clinical license (LPC, LCSW) preferred, and/or certification in case management (CCM)
• Minimum of 2 years of experience in inpatient utilization management in behavioral health, care coordination, and/or case management for high risk populations.
• Prefer experience with commercial and public payer sources
• Knowledge of complex medical and behavioral health conditions and national standards of care
• Knowledge and understanding of medical records, health insurance and billing criteria preferred
• Demonstrated ability to problem-solve complex, multifaceted situations with a client advocacy focus
• Strong organization skills, efficient time management and ability to manage and prioritize multiple tasks
• Excellent interpersonal skills
• Computer literacy on Microsoft Office products, spreadsheets, electronic health record systems and database programs
See job description