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- Manages and performs utilization reviews to ensure adherence to federal regulations and payer requirements
- Assists in maintaining records, answering correspondence and preparing and disseminating reports.
- Familiar with treatment concepts, practices and facility procedures that impact patient care
- Applies approved medical necessity criteria towards conducting admission and continued stay record reviews
- Acts as liaison with third party payers, managed care companies and billing company around communication specific to authorizations for approved patient admissions, continued stay, discharge planning and aftercare.
- Completes all utilization reviews for Detox, Residential, PHP, IOP and Community IOP levels of care.
- Sends out admission notifications when assessments are complete.
- Answers any questions regarding scheduling, etc.
- Obtains approval for alternative levels of care.
- Ensures that insurance companys specific questions are addressed in Utilization review interactions may require communication with clinicians and providers.
- Communicates denials or possible denials with treatment team to coordinate discharge plan.
- Requires after hours communication (text, email) with Chief Executive Officer, facility financial representatives or billing company when admission nursing assessment is complete.
- Occasionally provides information that billing company may send to appropriate parties.
- Adhere to all confidentiality laws and maintain ethical, professional boundaries with clients.
- Active participant in performance improvement and quality assurance initiatives that relate to documentation, specific payer initiatives and any payer-initiated action plans to improve facility performance
- Communicates any concerns relating to documentation and patient care needs to the appropriate departmental leader based on review of patient charts.
- Active participant of facility treatment team meetings
- Applies knowledge of managed care, pre-certification, concurrent reviews, medical/psychiatric diagnoses, medications and insurance payment practices.
- Helps with any other related activities or duties that are required.
- High School diploma or equivalent
- 3+ years' experience in healthcare setting
- Must pass State of Florida criminal background and driving record checks
- 401K match
- Medical, Dental, Vision Insurance
- Accident Injury, Hospital Indemnity and Critical Illness Plans
- Company paid Short & Long Term Disability
- Company paid Basic Life Insurance
- Paid Time Off
- Bereavement Leave
- Sick Time is based off of home location
- Employee Referral Program
Utilization Review Coordinator - Deerfield Beach, United States - BayMark Health Services
Description
Residential - Utilization Review CoordinatorRole and ResponsibilitiesPI24a631a31b9d