Utilization Review Coordinator

Sana Behavioral Health Las Vegas NV
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Position Title: Utilization Review Coordinator
Job Code: Utilization Review Coordinator
Position Type: Full Time Regular
Opening Date:
EEO Class: Professionals
Salary Range:
Position Location: Las Vegas, NV
Date Posted: 11/16/2018
Primary Job Duties:
Utilization Review Coordinator

Position Summary:
 The Utilization Review Coordinator interfaces with Admitting, Medical Staff, Inpatient Pharmacy services, Nursing, Discharge Planning, Adjunctive Therapy, and Court Services to ensure accuracy of payer information, clinical status, legal status and social services. The URC performs utilization review function per scope of services. Understands Center for Medicare/ Medicaid Services (CMS), and insurance requirements for pre-authorization, concurrent review, retrospective review and peer to peer review for patients admitted under voluntary or involuntary treatment status. 

Primary Responsibilities:
  • Able to organize clinical information to present a timely and cogent review for insurance companies, RSN and managed Medicare.
  • Responsible for maintaining current knowledge of federal and state regulations for Medicaid, Medicare and private insurance/managed care for utilization review (UR) purposes.
  • Maintains applicable documentation in electronic medical record including UR, clinical and financial authorization records and billing rules for the purposes of continuity of care and reimbursement.
  • Submits appeals for denied authorizations with applicable clinical, demographic and payer information.
  • Obtain preauthorization, initial authorization and concurrent authorization in a timely fashion as well as retro authorization when applicable.
  • Make informed decisions regarding appeal of decertification, based on review of available clinical documentation and through discussion with treatment team and Chief Nursing Officer
  • Identification and tracking of Medicare certification requirements and documentation.
  • Participate in Utilization Review Committee including presentation of cases, and discussion around meeting medical necessity criteria.
  • Participate in Utilization Review Coordinator/Admit team meetings as scheduled.
  • Maintain UR record and paper file for  insurance authorizations and communication.
  • Facilitate appropriate referrals to contracted vendor for single case agreements. Monitor completion of agreement with rate and effective date.
  • Follow organization infection control policies and procedures.
  • At risk for exposure to blood borne pathogens.
Requirements & Qualifications:
  • Bachelors Degree in Human Services, RN with BSN, or similar.
  • 3 years of experience in an inpatient mental health setting preferred.
  • Clinical licensure strongly preferred.
  • Knowledge of psychiatric/behavioral health systems.
  • Experience with utilization management highly desired.
Job Requirements:
Education or Skills: