The Utilization Review Specialist is an essential role at Mount Carmel Behavioral Health, an 80-bed inpatient acute treatment center for adult men and women who have been/currently are experiencing a wide range of mental or behavioral health challenges. The Utilization Review Specialist at Mount Carmel Behavioral Health, a joint partnership between Acadia Healthcare and Mount Carmel Health Systems, will serve as a partner to the UM department and other departments through the facility as a bridg... more details
The Utilization Review Specialist is an essential role at Mount Carmel Behavioral Health, an 80-bed inpatient acute treatment center for adult men and women who have been/currently are experiencing a wide range of mental or behavioral health challenges. The Utilization Review Specialist at Mount Carmel Behavioral Health, a joint partnership between Acadia Healthcare and Mount Carmel Health Systems, will serve as a partner to the UM department and other departments through the facility as a bridge between impacting direct patient care and financial stability of the facility.
Essential Functions include but not limited to:
Act as liaison between managed care organizations and the facility professional clinical staff.
Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
Conduct quality reviews for medical necessity and services provided.
Facilitate peer review calls between facility and external organizations.
Initiate and complete the formal appeal process for denied admissions or continued stay.
Assist the admissions department with pre-certifications of care.
Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.
Educational/Licensure/Skills Requirements:
Current and valid Licensed LPN in state of Ohio preferred.
Associate's Degree in Nursing OR Bachelor's Degree in Social Work, behavioral or mental health required. Master's degree in social work preferred.
Two (2) plus years' experience with the population of the facility and previous experience in utilization management required.
CPR/First Aid and De-escalation certifications required.
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