Utilization Review Manager

The Next Door

Apply

Job Summary

Mission: 

The Next Door provides a continuum of evidence-based substance abuse and mental health services for women in an environment of faith and healing to restore hope and a lifetime of recovery.

 

Summary:

Responsible for establishing and maintaining positive and effective communication with manage care companies. Aligns medical and counseling staff to ensure services are provided at the appropriate level of care in a timely manner consistent with the patient’s condition and in compliance with governmental and accrediting agencies.

Job Responsibilities

Primary Responsibilities and Duties include the following:

• Supervise Utilization Review Specialist.
• Train utilization review support staff as needed.
• Responsible for all admission placement decisions and completing intake with clients 50-75% of their daily time.
• Manage team on effective pre-authorization, concurrent review and discharge communication with insurance companies in a timely manner.
• Conceptualize client cases and create clinical impressions to present to all Managed Care representatives.
• Collaborate, negotiate and advocate with manage care companies to ensure the best services to our clients along with UR team.
• When needed, conducts pre-certification call or fax clinical forms after the completion of the intake assessment by interfacing with the clients managed care company. Will complete or schedule peer to peer reviews if initial request is denied.
• Reviews and understands insurance information provided by the admissions office, clarifies which benefits are available to client, and/or any discrepancies.
• Collaborate with clinical team managers to ensure the services rendered are meeting expectation for quality of care and services.
• Analyze client’s records to determine legitimacy of admission, treatment, and length of stay in program.
• Interpret clinical documentation in preparation for concurrent request to extend the length of stay for client’s current level of care as appropriate.
• Advocate for the most appropriate number of days a client needs in each level of care based on clinical documentation. 
• Provide appropriate consultation to clinical staff regarding documentation.
• Communicates necessary and appropriate information to insurance agencies.
• Communicates necessary and appropriate information to the clinical team and benefits and billing department.
• Review clinical documentation to ensure it meets standards appropriate for insurance, licensure, state and accreditation.
• Conduct weekly internal chart audits at each review when applicable.
• Maintain utilization review tracking system.
• Attend weekly treatment team meetings.  
• Document appropriate information in agency’s database, Aura and/or spreadsheets.
• Additional responsibilities as assigned.

Qualifications

Education and Experience:    

• Master’s degree in Counseling, Social Work or related field preferred.
• Current license as an LPC-MHSP or LCSW is preferred. 
• 3-5 years experience in utilization review preferred.
• Experience in Behavioral Health Care and knowledge of the ASAM criteria preferred.  
• Knowledge of Mental Health and Substance Abuse Disorders preferred. 

 

Other Requirements:

1. Possess proficient computer skills Outlook, Word, Excel, and PowerPoint
2. Valid Driver’s license

All Employees will adhere to the following professional standards:

• Honor the agency mission:  The mission of The Next Door is to live out our faith by providing a continuum of evidence-based substance abuse and mental health services for women in an environment of faith and healing to restore hope and a lifetime of recovery.
• Consistently treat residents and co-workers with the utmost respect.
• Keep ALL information regarding staff, residents, diagnosis, group information, etc. confidential at all times.
• Work as a necessary part of the team effort.
• Model ethical and professional behavior at all times.
• Participate in ongoing meetings and trainings as required by the leadership of The Next Door.
• Be creative and assist leadership with ideas for improving the overall quality of the services and environment for the residents of The Next Door.
• Encourage and live the core values of The Next Door, Inc., at all times:
  • Love ~ We demonstrate what love looks like, so our women learn to love others in healthy ways and love themselves.
  • Faith ~ We welcome all people, and all will be cared for with Christ-centered principles.
  • Hope ~ We believe hope is within reach for all women.
  • Wholeness ~ God has a plan and purpose for a woman’s life and that is abundantly good.  She does not have to be defined by her past decisions.  God loves.  God forgives.  Every woman can be whole and complete.
  • Community ~ We are building a healthy community in which our women are contributing members of society.  We need one another.  We care for one another.  We will teach our women how to build their own healthy community.
  • Respect ~ We believe each woman deserves respect from us and from each other.  We believe each woman can learn to respect herself and others.
  • Encouragement ~ We believe that our words and actions should build one another up.  We inspire one another with love and good deeds.

Additional Information

Benefits

How to Apply

To apply, visit www.thenextdoor.org and click on “About Us”, then “Careers”.

Details

• Date Posted: August 4, 2020
• Type: Full-Time
• Job Function: Other
• Service Area: Health (Physical, Mental)