Utilization Review Manager
Position Overview: Directly supervises the function of Utilization Management and Financial Counseling within the inpatient facility. Coordinates utilization of patient care and ensures all personnel providing patient care comply with practice and documentation related to facility protocol, ASAM and payor requirements such that all patients are authorized for treatment via their insurance or self-pay funding source and that the treatment team is aware of authorized time for treatment and funding options. This includes overseeing the collection of patient financial responsibility in coordination with third party organization (Finpay). Additionally, the UR Manager is responsible for reviewing and overseeing the review of medical records and communicating missing components necessary to obtain authorization and reflect active patient care to the Clinical Supervisor, Clinical Director, and Director of Nursing. The UR Manager must always act as an advocate for extending patient treatment to support the clinical and medical treatment plan. This includes providing education to the Clinical/Medical Team surrounding ASAM and assisting the treatment team to identify all medical necessity criteria to facilitate insurance coverage. They must ensure any insurance denials are communicated to treatment team immediately and manages any appeals to expedite coverage for appropriate level of care. The UR Manager coordinates and resolves all billing related matters in coordination with the Patient Accounts Team including any issues involving UR related claims denials, unbilled days, COBRA cases, and outstanding retro authorizations. In coordination with the RCA Managed Care team as well as Operations team, they must analyze insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients. The UR Manager must be familiar with standard concepts, practices, and procedure for all levels of care.
- Works on UR team and assists other members of the treatment team to ensure appropriate utilization of services. This includes oversite and supervision of all UR related activity.
- Completes UR reviews, especially focused on challenging cases to overcome barriers in obtaining coverage for patient care.
- Provides information at the request of other members of the UR team and communicates all utilization issues that may compromise patient’s treatment immediately to treatment team.
- Consistently works to assist with the development of new and innovative systems/treatment planning ideas to help maximize patient care days.
- Assists other members of the UR team with concurrent review and precertification of services when needed.
- Attends treatment team and other required site and leadership meetings.
- Oversees the completion of discharge notification calls to the insurance company within one business day of patient discharge.
- Responsible for ensuring all data is documented in the clinical chart to extend length of stay and coordinates with all members of leadership to improve clinical/medical documentation.
- Works closely with insurance carriers to provide accurate information and obtain authorization of coverage.
- Documents all efforts to obtain authorization, authorized days, and details related to insurance denial and appeal efforts clearly and thoroughly in EMR. Ensures all UR staff are documenting thoroughly and as required in the Managed Care form in Avatar.
- Completes Unbilled Report weekly. Utilizes Census Report and other reports daily to resolve any administrative documentation issues, thus, preventing unbilled days.
- Schedules Peer Reviews/Appeals and completes as appropriate. Manages all denials closely and is informed of all details and next steps surrounding denied days.
- Coordinates with corporate departments such as Patient Accounts, Managed Care, and Operations to resolve billing, claims, unbilled, Cobra, insurance quality/incident reporting issues, and trends with payors.
- Escalates payor related problems and concerns to supervisors at the insurance company, obtains resolution, and proactively communicates trends of facility payors to Corporate Operations.
- Shares knowledge and experience working with in-network and out-of-network benefits to help maximize patient days.
- Consults and trains staff as needed on documentation best practices in cooperation with other department leaders.
- Assists other department leaders with patient chart compliance audits.
- Directly supervises the function of Financial Counselors and ensures patient financial responsibility is collected and all paperwork outlining financial obligations are signed and logged in medical record.
- Exhibits knowledge of all continuums of care, including admission, continued stay, and discharge criteria.
- Follows up on Chart Appeals, including all retro authorizations and Cobra cases.
- Responsible for hiring, training, coaching, counseling, and managing staff performance by regular supervision and feedback
- Assigns workload and ensures equity amongst staff
- This job description is not designed to cover or contain comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
Education and Experience:
- Bachelor’s Degree in human services, Psychology, or other related field & 3 years’ experience in Utilization Management (required)
- Master’s Degree in Human Services, Psychology, or other related field & 5 + years’ experience in Utilization Management and state license preferred.
- Excellent verbal and written communication skills.
- Excellent organizational skills with the ability to prioritize workload
- Proficiency in Microsoft Office Suite, including Word, Excel and PowerPoint
Customer Service: Demonstrates concern for meeting internal external customers’ needs in a manner that provides satisfaction for the customer within the resources that can be made available.
Problem Solving: Identifies problems, involves others in seeking solutions, conducts appropriate analysis, searches for best solutions; responds quickly on new challenges.
Communication: Comfortable using a broad range of communication to different audiences in diverse solutions.
Project Management: Coordinates the diverse components of the projects by balancing scope, time, cost, and quality.
Work Environment: May work in a variety of environments including professional offices, clinics, hospitals, or out-patient facilities. They spend much of their time on their feet, actively working with patients.
Physical Demands: While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands to finger, handle or feel objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, kneel, crouch or crawl. The employee must occasionally lift and/or move objects up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision and the ability to adjust focus.
Travel: Travel is primarily local during the business day, although some out-of-the-area and overnight travel may be expected
Job Location: Recovery Centers of America at Monroeville – 2380 McGinley Road, Monroeville, Pennsylvania 15146