Utilization Management Specialist - FTFort Worth, Texas
Coordinates utilization management reviews for all assigned inpatient, partial hospitalization and intensive outpatient program patients; follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with external review agencies. Obtains authorizations for services, coordinates peer-to-peer reviews for assigned caseload. Understands medical necessity criteria and faciliates accurate and timely documentation to support advocacy of services. Coordinates closely with Director of Utilization Management, Nursing and Clinical Services. Essential Functions: Coordinates activity and functions in a multidisciplinary department with Social Workers and Nursing staff to provide comprehensive care coordination and discharge planning for each patient. Seeks out information and resources and uses creative problem solving for complex discharge planning, quality of care and utilization issues. Mobilizes resources and intervenes as necessary to assist in achieving desired clinical outcomes within the desired time frame. Promotes effective and efficient utilization of clinical resources. Dedicated to Hope, Healing and Recovery
Conducts review for appropriate utilization of services from admission through discharge, evaluates patient satisfaction, and evaluates quality of care provided. Ensures documentation of all patient review records according to regulatory, legal and case coordination requirements and acts proactively to see that hospital resources are used appropriately.
Performs reviews for third party payors in an accurate and timely manner.
Communicates daily with physicians, hospital staff, family, community care providers, and patients to facilitate coordination of clinical activities and to enhance a seamless transition from one inpatient setting to alternative levels of care in hospital and outpatient settings. Acts as primary resource for other professionals in problem solving on a day-to-day basis. Remains current from a knowledge base perspective regarding reimbursement modalities, community resources, and legal issues that affect patients and providers of care.
Refers cases where patients and/or family would benefit from additional resource support to the assigned clinician or the Director of Clinical Services. Serves as a patient advocate with payers. Enhances a collaborative relationship to maximize the patient’s and family’s ability to make informed decisions.
Participates in interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, and ensure
Collaborates with clinical staff in the development and execution of the plan of care, and achievement of goals.
Demonstrates knowledge of the principles of growth and development over the life span and the skills necessary to provide age appropriate care to the patient population served.
Engages in individual or group counseling sessions pertaining to care and adjustment
Participates with physicians, nursing personnel, and other members of the management team in the planning of patient care services and the patient care plan. Coordinates the provision of information and guidance to patients, their families, and other hospital departments regarding the psychosocial aspects of patient’s post-discharge treatment and recovery programs.
Assists in identifying opportunities for improvement, participates in data collection and analysis, contributes to problem solving and identification of actions to be taken and effectiveness of those actions. Utilizes evidence-based tools to analyze and identify trends/patterns of performance through variance reporting to improve quality and satisfaction and monitor over and underutilization.
Works collaboratively with other departments to define and study areas of hospital inefficiency and participates in improvement projects. Develops an understanding of responsibilities for participation in QI activities. Participates in QI teams as requested. Assists in the development and implementation of best practices to optimize resource management to achieve desired outcomes.
Prepares statistical reports on department services and patient needs; participates in the billing procedures for services rendered as required. Provides education and support to Clinical Staff by attending staff meetings, small groups, and one-on-one education related to resource utilization, discharge planning, and psychosocial aspects of healthcare delivery. Dedicated to Hope, Healing and Recovery
Knowledge of Interqual Criteria Knowledge/Skills/Abilities:
Knowledge of government and non-government payor practices, regulations, standards and reimbursement.
Background in and knowledge of hospital-based and/or third party payor utilization management and discharge planning.
Knowledge of Medicare benefits and insurance processes and contracts.
Knowledge of accreditation standards and compliance requirements.
Excellent interpersonal, verbal and written skills in order to communicate effectively and to obtain cooperation/collaboration from division, region and hospital management, as well as physicians, payors and other external customers. Demonstrates good interpersonal skills when working or interacting with patients, their families and other staff members.
Ability to work under stress, often with conflicting priorities, and to respond quickly in emergency situations.
Ability to work independently and effectively with all levels of the organization.
Ability to work cooperatively and effectively as a team member and as a team leader.
Ability to maintain confidentiality of all patient and/or employee information to assure patient and/or employee rights are protected.
Approximate percent of time required to travel: LimitedQualifications
Education: Associate Degree in Nursing, Certification in nursing (LVN/LPN), or Master’s Degree in Social Work, Marriage and Family Therapy or Counseling from an accredited school. Licensure.Certifications: Independent Practive Scope license in state of practice, LCSW, LMFT, LCPC(IL) LPC, LPC-I(TX) or RN or LPN/LVN
Experience: Minimum one year experince in Inpatient Psychiatric Facility Utilization Management or three years experince in an Inpatient Psychiatric setting in Clinical or Nursing Departments
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