Acadia Healthcare McCallum Place - Utilization Review Specialist - St. Louis, MO in Saint Louis, Missouri

Essential Responsibilities

  • Provides leadership with potential review problems and discusses them with the multi-disciplinary team and Administration.

  • Documents all contact with payers and outcomes of reviews to ensure compliance and advises executive leadership of related issues and recommends any actions to improve internal Utilization Management processes and procedures.

  • Participate in department in-service/training programs.

  • Provides consultation and guidance regarding admissions and continued stay criteria for a variety of payors.

  • Reviews clinical documentation from denied stays against criteria to determine if documentation is adequate for requested treatment.

  • Provides consultation and guidance regarding the appeal process. Assists UR staff in creating effective appeal letters.

  • Provides group and individual training in person and via web conferencing on a variety of related topics.

  • Evaluates actual UR operations for compliance with mandatory policy and procedures.

  • Maintains current knowledge of applicable regulations and regulatory update in the behavioral health field.

  • Abundant data entry.

  • Initiates and modifies demographic information, physician and facility information, performs quality check of data feed information.

  • Validates that the request for authorization is complete or requests additional data from requesting physician if necessary.

  • Follow all regulatory policies and procedures, privacy and security standards in accordance with government agencies including HIPAA requirements.

  • Provides accurate and complete clinical information to payors based on synthesized documentation in the medical record.

  • Conducts utilization review on all assigned cases and ensures authorizations are completed timely with all dates of service reviewed.

  • Completes retrospective reviews on assigned cases when updated insurance information becomes available subsequent to admission or after discharge.

  • Communicates discharges timely to payors for all assigned cases.

  • Notifies attending physician, direct supervisor and unit staff of in-house denial decisions.

  • Collaborates with the treatment team regarding quality and completeness of documentation and serves as a resource for nursing and clinical staff on documentation requirements.

  • Communicates with the responsible staff when clinical documentation is unclear, incomplete, unprofessional, or not relevant to the Master Treatment Plan goals and/or fails to supports medical necessity criteria for continued stay at the current level of care.

  • Participates in routine weekly chart auditing as assigned to ensure ongoing compliance with regulatory requirements.

  • Discusses utilization review decisions with patients and/or family members as appropriate.

  • Coordinates with clinical staff regarding progress of discharge planning for patients whose care has been denied.

  • Effectively manages time by scheduling concurrent telephonic reviews in advance when possible to efficiently manage caseload and work hours.

Additional Duties and Responsibilities

Other duties as requested or assigned

Education and Experience Requirement

  • 3-5 years of nursing experience preferred (ideally in utilization management or hospital/acute care setting).

  • Must be CPR certified (or able to be certified).

  • Proficiency in medical management software utilized for utilization review, medical appeals, and case management.

  • Personal and professional track record that demonstrates a commitment to quality in health care

  • Demonstrated knowledge of operations and healthcare management; TJC, Title XXII, and other local, state and federal regulations.

  • Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion; fluency in a foreign language is a plus.

  • Computer proficiency in Microsoft Office

  • Must have basic knowledge of use and operation of standard office equipment.

  • Health questionnaire and Tuberculosis test required within 14 days of hire.