What are the responsibilities and job description for the Residential UM Specialist - Commercial Insurance Focus position at KidsPeace?
Job Summary
The Residential UM Specialist will have the responsibility of reviewing and assessing client documentation (i.e. symptoms, treatment, and progress) with regard to requirements for admission and concurrent utilization review norms as specified by Federal and State regulations, private/third party standards, and Residential policies. The Residential UM Specialist will have the responsibility of insuring that communication with the payer source is timely to ensure funding for services rendered.
Job Duties
- Serve as the liaison with outside funding agencies for the purpose of maintaining authorizations related to the client's need for the specific level of care
- Complete UM responsibilities for additional funding sources as directed by management
- QA Authorization reports prior to month end/bill drop
- Work with patient accounts to ensure correct claim output, timely filing requirements are met, and appropriate follow-up is taken
- Review and analyze Residential clients' records with regard to severity of illness/intensity of service while evaluating for appropriateness of the specific level of care standards
- Closely monitor authorizations/benefit assignments for residential clients whose active benefit assignments frequently change
- Prepare and present clients at the monthly residential UR Committee meeting
- Complete and document accordingly in the clients record all commercial insurance reviews, PA MCO reviews, authorizations, denials, and appeals
- Management of the daily census and priority payer counts
Qualifications
- Bachelor's Degree in appropriate discipline required
- Experience in utilization management/quality assurance (preferably psychiatric) preferred
- Experience in behavioral health, psychiatric field
- Experience with acute emotionally challenged children or adolescents preferred
- Must be at least 21 years of age
- Valid driver's license required
