Qureos Mentor

Southwood Children's Behavioral Healthcare

<div>Overview:
<p><b>
Southwood Psychiatric Hospital offers comprehensive mental health treatment programs for children and adolescents </b><b>ages 3-21 whose lives </b><b>have been disrupted</b><b> by mental illness. Our facility near Pittsburgh, Pennsylvania, provides many levels of care. Currectly we are lookingto fill an opening for an experienced Utilization Review Specialist to join the UR Team.</b><b>
</b></p><p><b>PURPOSE STATEMENT:</b></p><p>
Proactively monitor utilization of services for patients to optimize reimbursement for the facility.</p>
Responsibilities:
<p><b>
</b><b>ESSENTIAL FUNCTIONS:</b></p><ul><li>
Act as liaison between managed care organizations and the facility professional clinical staff.</li><li>
Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.</li><li>
Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.</li><li>
Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.</li><li>
Conduct quality reviews for medical necessity and services provided.</li><li>
Facilitate peer review calls between facility and external organizations.</li><li>
Initiate and complete the formal appeal process for denied admissions or continued stay.</li><li>
Assist the admissions department with pre-certifications of care.</li><li>
Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.</li></ul><p><b>
</b><b>OTHER FUNCTIONS:</b></p><ul><li>
Perform other functions and tasks as assigned.</li></ul><div></div><div><br>
SWOOD</div>
Qualifications:
<p><b>
</b><b>EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:</b></p><ul><li>
Required Education: High school diploma or equivalent.</li><li>
Preferred Education<b>:</b> Associate's, Bachelor's, or Master&rsquo;s degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.</li><li>
Experience: Clinical experience is required, or two or more years' experience working with the facility's population. Previous experience in utilization management is preferred</li></ul><div></div><p><b><br>
</b><b>LICENSES/DESIGNATIONS/CERTIFICATIONS:</b></p><ul><li>
Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.</li><li>
CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.</li><li>
First aid may be required based on state or facility requirements.</li></ul><div><b><br>
</b></div><div><b>ADDITIONAL REGULATORY REQUIREMENTS:</b></div><div><br>
</div><p><b><i>While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from par</i></b><b><i>ticular jobs when circumstances</i></b><br>
<b><i>(e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.</i></b></p><p>
We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual&rsquo;s characteristics protected by applicable state, federal and local laws.</p></div>

Utilization Specialist

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Southwood Children's Behavioral Healthcare

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Utilization Specialist