Utilization Review Clinician

Overview

• Serve as a Utilization Review Clinician within a multidisciplinary team, ensuring compliance with managed care and CMS quality measures.
• Conduct pre-certification, concurrent, and discharge reviews, appeals, and denials to optimize patient care and resource utilization.
• Act as a liaison between healthcare providers and payor sources, facilitating effective communication and collaboration.
• Utilize clinical expertise to integrate treatment and financial information for utilization management programs.
• Contribute to the development and implementation of utilization management strategies in a fast-paced environment.
• Work on-site in a state-of-the-art facility, collaborating with professionals dedicated to patient care excellence.

Key Responsibilities & Duties

• Perform utilization reviews to ensure compliance with managed care and regulatory standards.
• Manage appeals and denials processes, providing detailed documentation and communication.
• Collaborate with healthcare teams to optimize patient care plans and resource allocation.
• Maintain accurate records of utilization management activities and outcomes.
• Provide expertise in psychiatric patient treatment and mental health care delivery systems.
• Ensure adherence to organizational policies and procedures in utilization management practices.

Job Requirements

• Master's degree in a related field or RN qualification required.
• At least 3 years of experience in utilization management, with 4 years preferred.
• License eligibility (LMHC or LICSW preferred) or RN certification.
• Knowledge of psychiatric patient treatment and managed care environments.
• Strong communication skills and ability to integrate clinical and financial information.
• Ability to work autonomously in a multidisciplinary, fast-paced environment.
• Proficiency in utilization management software and tools.