What are the responsibilities and job description for the Utilization Review Coordinator (PD) position at Prime Healthcare Services?
Overview
At Saint Clare's Health, our dedicated team of professionals is committed to our core values of quality, compassion, and community. As a member of Prime Healthcare, Saint Clare's Health is actively seeking new members to join its award-winning team!
Saint Clare's Health includes CMS 5-Star Rated hospitals and is an award-winning provider of safe, high quality, compassionate care, serving the communities of Morris, Warren and Sussex counties. Its network of hospitals and healthcare facilities include Denville Hospital, Dover Hospital, Behavioral Health Centers in Boonton, Denville, and Parsippany, and an Imaging Center in Parsippany, among other satellite locations. The hospitals have received multiple quality awards including Leapfrog “A” ratings for patient safety; Healthgrades recognition for orthopedic surgery, treatment of stroke, heart care, various surgical procedures, and more. For information, visit www.saintclares.com.
Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf
Responsibilities
Responsible for the quality and resource management of all patients that are admitted to inpatient behavioral health units from the point of their admission and across the continuum of the health care management. Responsible for contacting external case managers and managed care organizations for pre-authorization, concurrent reviews and appeals/denials management throughout the duration of a consumer’s stay. Assists the treatment planning team in understanding insurance requirements and completes UR audits for billing compliance. The methodology is designed to facilitate and ensure the achievement of quality, clinical and cost-effective outcomes and to perform a holistic and comprehensive admission and concurrent review of the medical record for the medical necessity, intensity of service and severity of illness.
Qualifications
EDUCATION, EXPERIENCE, TRAINING Required Qualifications: 1. Bachelor’s degree in Social Work, Psychology or other health related field.2. Knowledge of DSM 5 diagnosis and medical necessity criteria for behavioral health levels of care. 3. Knowledge of basic psychological and medical terminology. Preferred Qualifications: 1. Master’s degree in Social Work, psychology or other health related field is highly preferred. 2. One year of experience in direct care (inpatient or outpatient) mental health, case management, discharge planning or nursing management is preferred.
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