ESSENTIAL FUNCTIONS:

At Crestwyn Behavioral Health, you will have an opportunity to shine in your Utilization Review skills! You will:  

Act as liaison between managed care organizations and the facility professional clinical staff. Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements. Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay. Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office. Conduct quality reviews for medical necessity and services provided. Facilitate peer review calls between facility and external organizations. Initiate and complete the formal appeal process for denied admissions or continued stay. Assist the admissions department with pre-certifications of care. Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.

OTHER FUNCTIONS:

Perform other functions and tasks as assigned.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

Bachelor's or Master’s degree in social work, behavioral or mental health, nursing or other related health field required. Two or more years' experience with the population of the facility and previous experience in utilization management preferred.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

Current clinical professional license or certification, as required, within the state where the facility provides services preferred.