RN- Utilization Management Review Coordinator (Partially Remote)

Employment Type

: Full-Time

Industry

: Healthcare - Nursing



Job Details

Description

Community Bridges, Inc. (CBI) is an integrated behavioral healthcare agency offering a variety of different programs throughout Arizona. CBI provides residential, outpatient, inpatient, patient-centered medical homes, medication-assisted treatment, and crisis services to individuals experiencing crisis, opioid use disorder, homelessness, and mental illness.

 We currently have an opening for an RN- Utilization Management Review Coordinator for our administration offices.

 The UR Coordinator is responsible for ensuring that all patients have the correct benefit type for the service being received and completes and/or verifies that facility staff obtained the appropriate authorization for services and documents the authorization accordingly. The UR Coordinator will track each authorization and ensure timely filing and documentation of pre-certifications, concurrent reviews and discharge requirements by payor. The UR Coordinator is responsible for submitting deliverables to the UM Manager daily, weekly and monthly as required.

Process and Practice Development

  • Responsible for making recommendations for process improvements and report any barriers experienced by the UM department.
  • Responsible for coordination of the flow of patients from medical management teams, completes referral in the EMR, collects medical records for completeness, identifies availability of appropriate bed placements and ensures timely review for acceptance/notification of denials.
  • Ensures all coordination of care & authorizations are documented accordingly prior to departure of each shift.
  • Responsible for maintaining call logs, productivity reports and status reports.
  • Attends weekly staff meetings and at least one UM Team meeting per month in person.
  • Protects each patient’s confidentiality within the parameters of federal guidelines and established policy and process.
  • Adheres to established policy and process for this assignment.
  • Other duties as assigned by supervisory and administrative support.
  • Pre-certification of Services (Authorizations)

  • Responsible for ensuring that CBI has obtained authorization for medically necessary services provided to patients.
  • Ensures Notice of Admissions are submitted as appropriate within the required timelines of the payors.
  • Reviews admissions daily for each assigned program to ensure that any pre-certification is completed appropriately.
  • Reviews bed board daily to ensure that length of stay for each program is within authorized duration. Additionally, provides notice to program management and staff regarding upcoming and overdue authorization expirations.
  • Responsible for ensuring that the Certificate of Need (CON) and Prior Authorization (PA) forms by payor are completed by appropriate medical staff, and submission to the respective payors of services within the required timelines established by that payor. 
  • Once an authorization decision has been made, then the UR Coordinator will either load the authorization into the electronic medical record with treatment units that have been authorized or is responsible for appealing the denial as outlined below or following established appeals process. 
  • Provides educational support to staff on admission criteria for each level of care that incorporate medical criteria to meet each of the contracted payors and private insurance standards for CBI programs. 
  • Requests retro reviews from Medical Records and mails them to the requesting payors. 
  • Documents each mailed out retro review and complete follow up to ensure review was received by appropriate party and authorization is obtained.
  • Pulls admit/discharge report daily and verifies all private insurance admits had insurance verified and authorization obtained.
  • Completes daily spreadsheet that lists private insurance admits and what follow up is still needed. 
  • Ensures each authorization obtained and status of any pending authorizations is documented in EMR.
  • Concurrent Reviews

  • Responsible for obtaining authorization for concurrent reviews for patients who have exhausted their initial authorization but still require ongoing treatment. This will be accomplished through submission of payor specific requirements. 
  • For internal re-authorizations, the clinical staff will identify those patients who have exhausted their initial authorization for services. It is then the responsibility of the clinical team to staff the case with the UR Coordinator, and the UR Coordinator to identify whether the patient meets requirements for ongoing treatment.
  • Protects each patient’s confidentiality within the parameters of federal guidelines and established policy and process.
  • Adheres to established policy and process for this assignment.
  • Other duties as assigned by supervisory and administrative support.
  • Appeals of Denials

  • Apply critical thinking skills to each unique appeal or reconsideration request, applying applicable legal and state/federally mandated rules to processing.
  • Craft, edit, and finalize detailed and accurate written communication in the method of letters and client communications.
  • Conduct outreach regarding appeal status, determinations, and explanations with a high level of confidence and accuracy
  • Communicate with dignity and meticulousness in scenarios with members, providers, internal and external customers
  • Collaborate effectively within a team environment
  • Ensure that for all decisions that involve medical services (i.e. medication, inpatient detoxification) the Medical Director is involved in the appeal investigation. 
  • Ensures that all appeals investigations should be completed within timely filing guidelines of receiving the notice to appeal.
  • Protects each patient’s confidentiality within the parameters of federal guidelines and established policy and process.
  • Maintains files and logs related to all appeals.
  • Skills/ Requirements:

  • Requires a Master’s Degree in counseling, social work, nursing, or a related area, and at least 5 years of experience in the field of behavioral health or healthcare OR
  • Registered Nurse and 5 years of experience in the field of behavioral health or healthcare.
  • Familiar with a variety of the field’s concepts, practices, and procedures, including but not limited to, standard levels of care, DBHS, medical necessity and CMS guidelines. Relies on extensive experience and judgment to plan and accomplish goals. Performs a variety of tasks. Leads and directs the work of others across multiple disciplines within the department. A wide degree of creativity and latitude is expected. Reports to the Chief Operating Officer.
  • Must be at least 21 years of age.
  • CBI Offers an excellent benefits package!

  • Medical, Dental, Vision, Disability, Life, Supplemental plans - Hospital indemnity/ Critical Illness, Pet Insurance, Dependent Care Savings, Health Care Savings, 401K with employer match - 100% vested upon enrollment, Generous PTO accrual, Wellness programs, Tuition Reimbursement and Scholarship Programs, incentives, and more!
  • For the past four years, The Phoenix Business Journal has recognized CBI as one of the top ten healthiest mid-size employers in the Valley.
  • CBI treats patients from all different walks of life and believes in maintaining the dignity of human life. Recovery is possible!

    Qualifications

    Skills

    Behaviors

    :

    Motivations

    :

    Education

    Experience

    Required

    5 years: Behavioral Health field

    Licenses & Certifications

    Required

    Az State Board of Nursing


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