Job Description

Department:

Utilization Management

Reports to:

Director, Utilization Management

Status:

Non-Exempt

Essential Duties:

• Conduct admission reviews working with Assessment and Referral Services to stay abreast of admissions.
• Conduct concurrent and extended stay reviews on appropriate day and/or specified time.
• Prepare and submit appeals to third party payors, effectively coordinating collection of all pertinent data to support the hospital and patient’s position.
• Call/fax discharge information to insurance companies within 24 hours of discharge to ensure the facility is paid for the hospital stay.
• Maintain and update logs of review and maintain other appropriate records of the Utilization Review department.
• Communicate pertinent third party payors issues to doctor and treatment team.
• Attend daily treatment team meetings to discuss acuity issues, third party payors needs and gather information for reviews.
• Work independently in gathering information for reviews from the patient record, taking the initiative to seek information from members of the treatment team.
• Understand and communicate insurance information to team members, including benefits and levels of care offered.
• Perform internal utilization reviews as indicated.
• Prepare any reports assigned or requested by COO.
• Identify, document, and report any and all instances of adult or child abuse and neglect to the appropriate parties including a member of management, the police, and state agencies

Other Duties and Responsibilities :

• Stay abreast of applicable UR trends.
• Will adhere to all safety policies and safe work practice.
• Will adhere to all hospital policies and procedures.
• Exhibit Service Excellence and support facility internal and external customer service standards.
• Perform other duties as assigned.

Staff Development Requirements:

Employee will participate in General Hospital Orientation and Department / Job Orientation, including competencies for this position.  Will attend hospital safety trainings as required.

Every year, employees must participate in DBHS annual staff requirements, including testing for Tuberculosis.  Staff members must attend all mandatory in-services and are encouraged to participate in activities that enhance their professional growth and development.

Employees will receive performance appraisals/evaluations 90 days post hire date and then annually.

Physical and Mental requirements of Job:

Able to stop, crouch, reach, walk, and stand for sustained periods of time; use extremities to press against something with steady force, as well as pull objects, using extremities to draw, drag, haul, or tug in a sustained motion; able to feel, grasp, and finger objects and lift them from a lower to higher position or horizontally from one position to another; express and exchange ideas via spoken or written work to convey detailed information in an audible and quick manner, able to make fine discriminations in sound and to perceive the nature of sounds with no less than a 40lb loss @Hz, 1,000 Hz and 2,000 Hz, with or without correction; able to substantially move wrist, hands and/or fingers in a repetitive motion.

Must be able to exert up to 20 lbs. of force occasionally, and/or up to 10 lbs. of force frequently, and occasionally exert up to 50 lbs. of force.

Visual Acuity:

Visual acuity required adequate for preparing and analyzing data and figures, accounting, transcription, characters on computer terminals, reading, and visual inspections necessary.

Physical Surroundings:

The worker is not substantially exposed to adverse environmental conditions.

Emotional or Mental Stress:

Must be able to work with several distractions including light conversations.  Must be able to deal with aggressive, hostile and irrational behaviors of patients and outside vendors.  Must be able to respond immediately in crisis situations concerning patients and/or family members.

The worker may be subjected to environmental conditions that occur inside and outside via routine travel; much work, however, occurs inside under typical hospital conditions.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification.  They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills of personnel so classified.

Education Requirements:

MSW or MS in a recognized mental health field or Registered Nurse, a minimum of one year experience in case management and/or hospital experience

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