Position Summary: Responsible for proactively monitoring the utilization of continuum services and optimize reimbursement for the system. Reviews clinical documentation on each patient and works directly with managed care or insurance companies/entities performing concurrent, live reviews with provided clinical documentation to get additional patient days authorized for payment as needed. Communicates with the inter-disciplinary team members to ensure optimal length of stay for patients depending on their continued medical necessity for treatment or care; reviews and provides feedback to the Medical Director, psychiatrists, DON and clinical leaders as to quality of documentation to support continued medical necessity
Essential Functions:
- Develops and maintains effective working relationship with all disciplines
- Advise treatment team when clinical criteria have been inadequately documented
- Obtains additional information from Medical, Nursing, and Social Services as needed to determine medical necessity for continued stay
- Manages workload in an effective manner
- Obtain daily clinical documentation to assess for accuracy and completeness
- Organizes information daily for each case to be presented to Third party payers for continued authorization.
- Conducts concurrent reviews daily
- Files Appeals for denials as indicated.
- Evaluates information in patient record for medical necessity of continued stay at current level of treatment
- Assimilates all clinical information into a concise, cogent product.
- Completes all needed case reviews and needed follow up daily
- Completes all data entry of review results in the client information system daily
- Completes all data entry of review results in Approval /Denial Log daily
- Communicates effectively with managed care and referral sources.
- Maintains positive working and collaborative relationships with insurance and managed care providers.
- All other duties as assigned
Minimum Qualifications:
Education: Associate’s Degree or higher preferred in: Nursing, social work, psychology, health information management or other healthcare field is preferred, or related experience. May substitute Degree with High School Diploma with minimum of 4 years Psychiatric/Mental/Behavioral Health Experience.
Experience: Experience in a psychiatric setting, knowledge of health care service delivery systems, and third-party reimbursement preferred; knowledge of managed care environment.