Job Summary: Conduct pre-certification and utilization management functions for all behavioral health and substance abuse services offered by the Brattleboro Retreat. Engages in ongoing contact with managed care company representatives to provide initial clinical data for pre-certification and concurrent case review to ensure authorization of all necessary days at the most appropriate level of care. Conducts concurrent chart and retrospective review as requested by the Director of Utilization Management and Contracting. Communicates information to clinical staff, physicians, and fiscal services regarding days/services approved, information required for ongoing review, review schedule, denial of stay, and, coordination of Physician to Physician review, and/or appeals
QUALIFICATIONS:
1. Working knowledge of level of care criteria.
2. Working knowledge of regulatory agencies preferred.
3. Working knowledge of insurance and managed care companies preferred.
4. Excellent written and verbal communication skills, flexibility, strong team member and ability to establish positive working relationships with a variety of clinical staff.
5. Clinical knowledge.
6. Bachelor's degree in related field preferred.
7. Two years' experience working in behavioral health field, hospital setting preferred.
8. Experience with computers, data entry; and, Microsoft Office.
9. Excellent organizational and time management skills.
10. Possesses the ability to work under pressure while maintaining proper composure and a professional demeanor.
11. Experience and proficiency with Avatar required.
12. Experience with McKesson InterQual preferred.
ESSENTIAL DUTIES AND RESPONSIBILITIES:Core Competencies
Communicates pertinent Clinical information to external review agencies for CCR.
Assesses written clinical information from all appropriate resources.
Coordinates communication with physician and other clinicians involved with the care of patients for the purpose of collecting relevant clinical information for presentation to external review agents.
May recommend to treatment team what documentation is required to justify the services being requested.
Communicates with physician and treatment team members information received from external review agents regarding pre-certification and continued stay requirements.
Determines if clinical information contained in the medical record complies with the established LOCUS Criteria for the level of care within which the patient is currently being treated.
Appropriates physician to physician reviews.
Thoroughly enters all data into the proper databases.
Demonstrates initiative, the ability to work independently, the ability to work with treatment team members, professional judgment/demeanor, and, effectively performs other duties as assigned.
Obtains authorization for all services (i.e. Psychological testing).
Works with Patient Account Representatives regarding authorization issues that are affecting claims.
Highly proficient in organization, prioritization, and time management.
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