Utilization Review Manager, Beverly Hospital - A Sheppard Pratt Partner - Amesbury, MA

General Summary

Under general supervision provides day-to-day leadership of the utilization review process of patients admitted to the Hospital for Inpatient and Day Hospital levels of care. Trains or ensures the proper training of newly hired Utilization Review Coordinators coordinates work assignments and provides effective liaison between Admissions and Finance/Revenue Cycle. Communicate with clinical programs and other internal departments as needed. Updates the Hospital Utilization Review Plan and ensures that the plan is administered as documented. Performs the full range of duties associated with Utilization Review Coordinator during coverage for absences and vacancies or as workload requires. These duties include the review of patient medical records for evidence of medical necessity and appropriateness of admission/continued stay case review for appeals of payment denials and the review and assessment of the adequacy of clinical information sent to insurance companies. Maintains and reports as collaboration with the residents interdisciplinary treatment team we perform a full range of aftercare and discharge planning services. Develops and assists in the implementation of discharge and aftercare plans; works with residents and families to facilitate the community transition and assure appropriate match to patients needs.

Principal Responsibilities and Duties:

Customer Relations/Marketing

• Communicate in a therapeutic respectful way with patients at a level of understanding.

Assessment of Need for Medical Necessity

• Annually reviews and revises the Hospitals Utilization Review Plan to incorporate revisions to the Joint Commission (TJC) requirements Commonwealth of Massachusetts regulations and current trends and developments in utilization review.
• Implements agreed upon goals and objectives and participates in annual evaluation and revision of plan.

Supervision

• Selects directs appraises work performance and job competency and as necessary disciplines and discharges assigned Utilization Review staff.
• Trains and orients newly hired Utilization Review Coordinators.

Operational Leadership

• Provides day-to-day direction to ensure the equitable distribution of utilization review assignments.
• Assists Utilization Review Coordinators and Financial Case Management Representatives in resolving problems.
• Reviews all cases for appropriateness of filing additional appeals after denial of payment has been received.
• Maintains utilization of review data and prepares reports as requested.

Internal Liaison with Other Departments

• Provides effective liaison with the Finance Office and clinical programs to clarify and ensure appropriate use of utilization review role regarding new and/or revised procedures and programs.
• Works with staff of the Managed Care Contracting office in response to requests for information documentation or follow-up regarding a case or specific concerns regarding coverage or denial of payment.
• Reports to the Department of Psychiatry appropriate updates and statistics as directed by

Utilization Review Workload

• Reviews and screens medical necessity and appropriateness of patient admissions and continued stay.
• Conducts case review to determine justification for appeals in response to actual or prospective payment denials.
• Reviews and assesses adequacy and appropriateness of clinical information sent to insurance companies.
• Identifies and refers problem areas/deficiencies to appropriate internal resources.
• Prepares monthly statistical reports on utilization review activities and additional narrative or statistical reports as requested.
• Ensures ongoing education of clinical staff regarding insurance requirements and medical record documentation.

Aftercare Planning

• Collaborates with outpatient providers family and team members to determine necessary followup services.
• Educate patients and families regarding options for discharge to include what is available and what has been arranged for follow-up.
• Schedule appointments with appropriate referral sources prior to discharge.

Knowledge Skills and Abilities Required:

• Work requires comprehensive knowledge of a broad range of medical diagnoses treatment modalities therapeutic services and intervention techniques and knowledge of utilization review practices and procedures acquired through a Masters degree in social work counseling nursing or related field
• Work requires three to five years of progressively more responsible utilization review experience in a psychiatric setting in order to provide leadership for the Utilization Review Program in compliance with the Joint Commission (TJC) and Commonwealth of Massachusetts requirements understand insurance company/payor policies and issues and effectively represent department in liaison role.
• Work requires interpersonal skills sufficient to provide leadership to assigned staff and to communicate with tact and diplomacy with a variety of clinicians and other Hospital staff as well as third-party reimbursement payers and reviewers in gathering and exchanging information consulting and solving problems (51-80% of work time).
• Work requires a relatively high level of analytical skill sufficient to collect analyze and interpret data to determine importance of information collected form inferences and/or forecasts on how to utilize data and prepare abstracts and summaries of statistical information for reports.
• Work requires the ability to concentrate and pay close attention to detail (51-80% of work time) when collecting and analyzing data maintaining files and preparing required reports and very frequently produces a high level of mental/visual fatigue.
• Work requires walking and standing (6 - 20% of work time) when visiting Hospital locations in order to gather data or talk with internal staff and clinicians.

Required Experience:

Manager