UR/CASE MANAGER
Required skills
- BSN
- BSW
- LMSW
- LMHC
- DSM 5-TR
- InterQual criteria
- HIPAA
- EMR
- chart audits
- clinical rounds
Role summary
The Utilization Reviewer will be responsible for overseeing that assigned hospital patients are reviewed and are meeting ongoing medical necessity as per InterQual criteria. This will include chart audits as well as clinical rounds and direct observation. Responsibilities include conducting utilization reviews with insurance companies, obtaining pre-certification, determining medical necessity, collaborating with hospital staff, utilizing EMR, ensuring compliance with hospital policies and HIPAA, and completing appeals and retro-authorizations.
Summary/Objective
Psychiatric Utilization Reviewer
The Utilization Reviewer will primarily be responsible for overseeing that assigned hospital patients are reviewed and are meeting ongoing medical necessity as per InterQual criteria. This will include chart audits as well as clinical rounds and direct observation.
Responsibilities:
- Conduct initial, concurrent, and discharge utilization reviews with insurance companies for in-house psychiatric patients.
- Obtain pre-certification for new patients not already authorized by the sending facility.
- Determine and convey medical necessity as per InterQual criteria for each patient.
- Collaborate with UR staff, social workers, providers, and other hospital staff on a regular basis regarding patient care and treatment as well as authorization.
- Access and utilize EMR while maintaining the highest standards of documentation and other protocol.
- Maintains professionalism while working as a part of a team towards the larger goal of ensuring compliance of staff with hospital policies and patient care standards.
- Understands and complies with all HIPAA rules and regulations
- Completes appeals and retro-authorizations as directed by UR Director.
Requirements/Qualifications:
- Excellent communication skills
- Attention to detail
- Bachelor’s degree ( BSN preferred)/Master’s degree (BSW,LMSW,LMHC)
- Knowledge of behavioral health, including DSM 5-TR
- Knowledgeable in using Microsoft Office, Excel, and Outlook
- Ability to work as part of a collaborative hospital team
- Experience working with electronic medical records
Job type:
- Full time
Shift and schedule:
- Day shift
- Monday to Friday
- Expected hours: 37.5 per week
Benefits:
- 401(k)
- Flexible schedule
- Paid time off
