What are the responsibilities and job description for the Utilization Review (UR) Coordinator position at APALACHEE CENTER INC?
Job Details
Description
Apalachee Center, Inc. is best known for helping individuals and families of North Florida succeed in recovering from emotional, psychiatric, and substance abuse crises. Apalachee Center, Inc. provides comprehensive behavioral health services across 8 counties (Franklin, Gadsden, Jefferson, Leon, Liberty, Madison, Taylor, and Wakulla Counties).
Apalachee Center, Inc. offers competitive benefits for our full-time positions to include health, dental, vision, basic life insurance, long term disability, paid time off, and more.
Overview:
Coordinate and conduct Utilization Management functions for the Agency in accordance with established policies, utilization management plans, and unit procedures. This is an office-based position (Leon County) and is not eligible for remote work.
ESSENTIAL/CORE JOB-SPECIFIC DUTIES AND RESPONSIBILITIES
- Conducts the following Utilization Management activities in accordance with Agency policies, insurance contractual requirements, and quality indicators:
- Inpatient admission certifications / authorizations;
- Continued stay reviews for applicable insurances;
- Submission of discharge clinicals to applicable insurances within 48 hours of discharge;
- Daily documentation of authorization information in the electronic health record (EHR);
- Identify all denials warranting appeal; work in conjunction with the Billing & Insurance Department to complete and submit formal appeals in accordance with insurance / managed care requirements;
- Notify Inpatient Program Director / Associate Director, Attending Practitioner, Medical Director, Administrative Services Director, Chief Operations Officer, and Director of Patient Financial Services of all inpatient denials.
- Coordinate with the Central Receiving Facility (CRF) and the Billing & Insurance Department to ensure prior authorizations occurred as required. Work in conjunction with CRF to complete outstanding prior authorizations. Complete Outpatient UR authorizations on an as needed basis.
- Review compliance with Inpatient Medicare certification (admission and continued stay) and coordinate with hospital staff to ensure documentation is completed in accordance with UR policies, plans and procedures. Assist the Administrative Services Director in Recovery Audit Contract (RAC) activities.
- Attend and participate in treatment team and staffing meetings on the inpatient units to coordinate UR activities with the client’s treatment team. Provide ongoing consultation and education to clinical staff and practitioners regarding documentation issues required by insurance/managed care companies. Provide technical assistance to the programs in UR activities.
- Complete monthly, quarterly, Year-to-date UR reports (ALOS, Admissions/Discharges, Readmissions, etc.) of inpatient/residential units, and distribute profiles. Complete monthly hospital census in data warehouse. Complete other Quality Improvement activities as instructed by Administrative Services Director.
- Serve as Chair for the Utilization Management Sub-Committee (scheduling, agenda development, meeting minutes, and follow-up. Complete annual update of the Agency’s Utilization Management Plan.
Qualifications
Education/Experience:
- Bachelor's Degree with a major in Psychology, Social Work, Counseling, or human services-related field.
- Professional experience may substitute for the required Bachelor’s degree
- One year of related professional administrative experience in utilization management/quality assurance preferred.
- Professional clinical experience in a psychiatric / community mental health setting preferred.
- Familiarity with Joint Commission, Children & Families licensure regulations, Medicaid, Medicare and managed care standards preferred.
- Familiarity with Healthcare Effectiveness and Data Information Set (HEDIS) measures preferred.
Licensure or Certification:
- Valid Driver’s License preferred
Salary : $20 - $22
