Utilization Management (UM) Coordinator

Job Address:

Kids Thrive is currently recruiting a Utilization Management (UM) Coordinator to join our team!

Position Summary:

The UM Coordinator works with the Director of UM by providing the precertification and recertification process, peer to peer reviews, and appeal. The UM Coordinator will ensure an appropriate discharge plan is in place for each patient discharge. The UM Coordinator will accurately report the authorization, denials, and appeals status of patients to the UM Director. They follow department and facility procedures and ensure effective communication with all relevant departments regarding patient care needs.

Estimated Pay Range: $27-34/hr

Job Duties:

• Responds to the request for services including the determination of appropriate level of care, initial authorization, the concurrent review process, and appropriate discharge planning.
• Reviews the quality of documentation for each level of care to ensure clinical effectiveness and appropriateness of treatment.
• Participates in clinical team review and evaluation of services offered at the facility to ensure goals and objectives are consistent throughout programs and facility expectations.
• Meets regularly with the UM Director to ensure compliance with program goals and objectives.
• Maintains an active involvement and awareness of all patient admissions, discharges and transfers to alternate levels of care. Works towards continuity of care for each level of care transition.
• Provides assistance with the coordination with managed care companies or other third-party payors regarding peer reviews, retrospective reviews and appeals. Documents and updates the denial log to reflect same.
• Maintains logs of all certifications and denials along with updated status of same.
• Maintains processes to minimize denials and communication of same to the CFO and Business Office Manager.
• Reviews benefit verifications and updates for level of care benefits with the Business Office to ensure and optimize maximum patient care and treatment.
• Ensures processes are followed to provide adequate continuity of care and communication to families/support systems as well as referral sources for treatment and aftercare planning.
• Reports results of daily treatment team meetings all discharges and status of high risk cases such as limited benefits, peer reviews, denials, or unplanned discharges.
• Strong working knowledge of external review organizations (ie: Medicare/Managed Care/Medicaid) with knowledge of payor resources and planning.
• Ability to state local laws, ordinances, and practices governing involuntary hospitalization and ensure compliance with same.
• Demonstrates an ability to be flexible, organized, and function well in stressful situations.
• Interacts professionally with patient/family and provides explanations and verbal reassurance as necessary.
• Maintains a good working relationship/team work both within the department and with other departments.
• Ensures that documentation meets current standards and policies.
• Manages and operates equipment safely and correctly.
• Supports and maintains a culture of safety and quality.
• Demonstrates understanding of HIPAA.
• Demonstrates understanding of Patient Rights and Patient’s Right to Report and Patient Advocacy.

Qualifications:

• Education: Bachelor’s Degree in Nursing, Social Work, Mental Health/Behavioral Sciences preferred.
• Experience: Direct clinical experience in a psychiatric or mental health treatment setting, including managing a related function preferred. Experience in patient assessment, family motivation, treatment planning and communication with external review organizations or comparable entities.
• License: LPN, RN, LMSW, LPC or applicable license preferred.
• Additional Requirements: CPR certification and Handle with Care training within 30 days of employment. May be required to work flexible hours and overtime including evenings, weekends, and holidays. All certifications are to be maintained during tenure of employment.