Essential Functions
- Utilization Management - Utilization Review, Care Transitions, & Coordination
- Providing clinical information to payers, monitoring length of stay, seeking necessary care authorizations and appealing denials as indicated within a timely fashion.
- Follows-up on lack of documentation for medical necessity, supporting documentation with discipline identified.
- Track and trend opportunities for improvement resulting in late Insurance Reviews, longer lengths of stay.
- Completes utilization reviews daily and/or as required by insurer, (concurrent and retro) for psychiatric appropriateness according to Hospital's approved criteria timely and efficiently.
- Demonstrates clinical expertise specific to the issuance of ABN/HINN notice to patients and/or legal significant other and care progression.
- Responsible for insurance interactions related to Medicare Important Message appeal process.
- Keeping physician and team informed of status change and documenting status.
- In collaboration with the BH Clinical Team provides education and information to patient, family and care providers as it pertains to continuing care, care management, LOS, re-hospitalization and assure understanding of disease management.
- Multidisciplinary Team Rounds -
- Participates in discharge planning teams daily.
- Works collaboratively with multidisciplinary team to determine each patient's needs concurrently including post-acute care when needed; addresses LOS issues, appropriate leveling of patient status; addresses, potential needs, resources, referrals for other disciplines etc.
- Quality & Statistical Data -
- Reviews medical record for abnormal findings, complications, delays and deviations from expected clinical outcomes reports such to Provider and/or Director to maintain an efficient, cost effective episode of care for each patient and documents intervention provided.
- Maintains current working knowledge regarding regulatory requirements and insurance review procedures, forms, and portal updates.
- Utilizes knowledge to redesign systems for improving performance.
- Continuously prioritizes projects, activities, and tasks to ensure deadlines and customer needs are met.
- Assists with preparation of reports/statistics as it pertains to staff specific workflow.
- Reviews pre-admission screen forms for accuracy. Note any pre-authorized dates of service and insurance specific communication related to concurrent review/discharge notification.
- Responsible for correcting issues with pre-auth to ensure reimbursement – including obtaining auth for patients who are admitted without proper auth in place.
- Conduct daily comprehensive utilization reviews for inpatient psychiatric and substance use disorders to ensure compliance with medically necessary criteria.
- Request administratively necessary days when a patient no longer meets criteria for inpatient level of care. Determine state involvement as reimbursement for DMH active clients differs from the standard Medicaid rate.
- Participate in 72 hour meeting with patient/HCP/Family/Guardian,Social Worker, and Unit Leader to facilitate education regarding anticipated LOS and advance discharge planning inititation/expectations.
- Attend collaborative meetings with insurers to review statistical trends, discuss complex cases, and review quality data reports.
- Denials/Appeal Process -
- Completes assessment of denial within 1 week providing supporting documentation with outcome of review; documents intervention in the UR EMR section.
- Coordinates Medical Director and Peer to Peer reviews in accordance with insurance regulations.
- Prepare written appeal letters, termination letters, discharge notices, MOON and IMs when appropriate as per regulatory standards and department policies.
- Report any variances, trends to director. Submits denials/appeals when completed.
- Collaborate with Director of Behavioral Health to address BH patient accounts where payment denial exists – work with denial mgmt team for resolution.
- Discharge Planning -
- Communication: In collaboration with BH Social Worker builds rapport and responds to needs of physician, reviewers for managed care plans, healthcare team members, 3rd party payers, outside reviewers and vendors to enhance internal and external customer service satisfaction.
- The Discharge Planning Process: Throughout patient admission collaborates with the BH Social Worker to provide assistance and guidance ongoing for discharge planning needs.
- Maintain sufficient familiarity with inpatient behavioral health social work functions, including discharge planning, care coordination, community referrals, family/collateral communication, resource identification, and documentation requirements, to ensure continuity of patient care during periods of Social Worker absence or increased unit need.
- Performs any and all other duties as assigned by director and/or designee.
Statement of Other Duties
This document describes the major duties and responsibilities for this job and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that employees may be asked to perform job-related duties beyond those explicitly described.
Functional Demands
Exerts 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Frequently reaches (extending hands and arms in any direction), handles (seizing, holding, grasping, turning, or working with hands), and feels (perceiving attributes of items such as size, shape, temperature, or texture by means of fingertips). Occasionally stoops (bending the body downward and forward by bending the spine at the waist), and kneels (bending the legs at knee to come to rest on knee or knees).
