Utilization Management Specialist

Utilization Management Specialist

River Edge and all subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates.  River Edge and all subsidiaries are equal opportunity employers and are fully committed to recruiting, selections, placement, promotion and compensation of individuals without any regard to race, color, religion, age, sex, (including pregnancy, gender, identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal or state laws.

The Utilization Management Specialist monitors appropriate utilization of services throughout the course of treatment for clients admitted to the inpatient and outpatient program and coordinates authorization with third-party payers.  The UM Specialist reviews cases for appropriateness of admission, continues stay, and discharge planning while assisting in the promotions and maintenance of high-quality patient care.

This position ensures that the clients have the appropriate level of care, client status, authorizations status, plan of care and meet medical necessity for the behavioral health services.  This role ensures that a patient’s payor has the clinical information with which to authorize the behavioral health and continued stay services to include covered days and associated services.

You will :

• Create Connects batch files.
• Retrieve and process response files from Beacon’s SFTP site.
• Work Connects documents in rejected, denied, hold, no CID, multi-final payer and status appropriately.
• Review discharge connects and flip to UM complete.
• Manage and process BHL CSU authorizations and update Carelogic.
• Review and process AC file for BHL CSU authorization.
• Complete State Discharge process for Fulton locations.
• Create PTRF referral via Beacon authorization request.
• Review and process Connects documents in UM review.
• Run Service delivery, service history, service history (staff credential), ADA group and failed claims reports.
• Manage Carelogic client discharge process.
• Review each client record discharge request and create discharge connects, discharge summary.
• Knowledge of the psychiatric and accreditation process by a community based behavioral health accreditation organization such as CARF.

Must have :

Additional Information :

The Application Process :

Diversity and Inclusion :

River Edge Behavioral Health is committed to creating a diverse and inclusive work environment and is proud to be an equal employment opportunity employer. All qualified applicants will receive consideration for employment regardless of race, color, religion, gender, gender identity or expression, sexual orientation, nationality, genetic make-up, disability, age, or veteran status.

Drug-Free Workplace :

River Edge Behavioral Health is a drug-free workplace with a longstanding commitment to providing a safe, quality-oriented, and productive work environment.  In compliance with the Drug-Free Workplace Act of 1998, all applicants must pass a satisfactory background clearance and pre-employment drug screen.