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Utilization Review Coordinator

We invite you to join our team.

APN Lodge is hiring a Utilization Review Coordinator ​in Edwards, CO.

This position is responsible for the development and on-going oversight of the Utilization Management (UM) Program for the All Points North Lodge residential treatment facility. Provides utilization management for prospective, concurrent, and retrospective review to best meet the specific behavioral healthcare needs of clients and to promote quality and cost-effective outcomes and appropriate payment for services.

Responsibilities include but are not limited to:

  • Responsible for all aspects (i.e. documentation, authorizations letters, etc.) regarding authorizations, utilization management, and coordination of IOP, PHP, and RTC care for clients accessing behavioral health benefits – must have a thorough understanding of the client’s treatment through coordination with the treatment team.
  • Responsible for obtaining prior authorizations for all services by successfully completing the authorization process with commercial payers. Contacts external case managers/managed care organizations for certification and recertification of insurance benefits throughout the patient’s stay and assists the treatment team in understanding the insurance company’s requirements for continued stay and discharge planning.
  • Facilitates and coordinates discharge planning and works towards the reduction of preventable hospital admissions, re-admissions, etc.
  • Performs telephonic reviews of inpatient and outpatient episodes of care.
  • Gathers pertinent clinical information and applies/interprets criteria to ensure medical necessity, covered benefits, participating providers, and appropriate services.
  • Assists with claim appeal authorization review as needed.
  • Contacts physicians offices to obtain medical records necessary to perform utilization review
  • Meets or exceeds regulatory turnaround time and departmental productivity goals when processing referral/authorization requests
  • Provides administrative support for UM processes such as triaging telephone requests from payers for information, notification or follow up, and organization of data related to admissions and discharges
  • Advocate that the patient is placed in the appropriate level of care and program.
  • Interface with program staff to facilitate a smooth transition at the time of transfer or discharge.
  • Work closely with Revenue Cycle Department to ensure the insurance precertification process is complete and to update the denial log statistics on an ongoing basis (at least weekly), and initiate appeals through telephone or written communication within 7 to 10 days of denial.
  • Provide clinical information to managed care companies, insurance companies, and other third-party reviewers to establish the length of stay or number of authorized services.
  • Processes and/or obtains authorizations/certifications based on payer requirements.
  • In conjunction with treatment provider, explain benefits, co-pays, co-insurances and deductibles to patients when necessary.
  • Document prior authorization and insurance verification notes in Electronic Medical Record, and work with the clinical team and clinical informatics to improve clinical documentation practices and processes to support quality clinical care.
  • Administer or participate in audits of programs to ensure agency compliance on utilization review regulations, and educate the front end and clinical team on ways to improve documentation and clinical outcomes.
  • Periodic monitoring and auditing of medical records for completeness and adherence to policy.
  • Manage referrals for and engage with current and new potential clients.
  • Assure appropriate release of information on file for clients.
  • Review requests for release of information and processes requests made by clients, attorneys insurance companies and other health care entities.
  • Ensure compliance with all local, state, and federal statutes prior to processing requests.
  • Obtain signed authorizations and monitors expiration dates.
  • Copies and scans medical information as requested.
  • Maintains Center medical records requests.
  • Mails or hand delivers copies of medical requests to individuals requesting information.
  • Maintains HIPAA compliance by utilizing a check system during the scanning process.
  • Review records sent through the health information exchange (HIE) assuring pertinent information is accurate, making corrections and uploading the records daily.
  • Upload documents into the electronic health record’s document library based on Center policies.
  • Complete Monthly Treatment Summaries and Coordination of Care documents, sending them to the appropriate external agencies to meet compliance requirements.

Education or Formal Training & Experience

  • Bachelor’s degree in a human-service related field required; Master’s-level preferred
  • Experience working in a medical records department, to include tasks such as purging, filing, and responding to record requests preferred
  • Understand insurance verifications, prior authorizations, co-insurances, deductibles and co-pays
  • Must have strong attention to detail and accuracy
  • Strong skills in problem solving, interpersonal and communication skills
  • Experience documenting and billing for services provided
  • Basic computer and keyboarding skills
  • Ability to enter data in The Center’s computerized record-keeping system
  • Ability to interact with people in a professional, friendly manner
  • Ability to work independently as well as cooperatively and constructively as part of an interdisciplinary team
  • Ability to lift up to 10 lbs
  • Able to pass urine drug screen and criminal background check.
  • Salary commensurate with education, certification, and relevant experience.

All Points North Lodge is an equal opportunity employer. All employment decisions are made without regard to race, color, creed, gender, age, religion, national origin, veteran status, sexual orientation, sexual identity, sexual expression, or disability that does not prohibit performance of essential job functions.

Interested in one of our career opportunities?

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