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Utilization Review / Case Management Specialist

Company: Community Health Systems
Location: Cleveland
Posted on: June 20, 2022

Job Description:

Job Description

The UR/CM Specialist at TBH is a critical part of the care team from pre-admission to post discharge. They assist team members with insurance verification and pre-certifications and are essential to the multidisciplinary treatment team in accurately interpreting resources needed throughout the treatment process and aftercare plan. They are responsible for using medical necessity criteria to conduct utilization review for medical necessity and level of care on all new admissions ensuring patient status is in keeping with MD orders and appropriate criteria.

The Utilization Review / Case Management Specialist at Tennova Behavioral Health is a critical part of the care team from pre-admission to post discharge. They assist team members with insurance verification and pre-certifications and are essential to the multidisciplinary treatment team in accurately interpreting resources needed throughout the treatment process and aftercare plan. They are responsible for using medical necessity criteria to conduct utilization review for medical necessity and level of care on all new admissions ensuring patient status is in keeping with MD orders and appropriate criteria. They coordinate with the multidisciplinary treatment team providing education on continued stay criteria and charting standards that meet medical necessity criteria, alert MD/team to non-coverage issues and directs next steps for any needed peer review and/or appeal processes, collaborate on issues that impact continuity of care post discharge and assist with discharge planning when needed. They coordinate with the business office to ensure insurance contacts are documented and collaborate on denials / appeals /coding, etc.. They participate in Quality Improvement activities for the Behavioral Health Service line as requested, maintaining statistics on denied days, readmission trends, AMA, etc.

POSITION QUALIFICATIONS

Education:

Medical field licensure or certification such as RN/LPN/CTRS required; or equivalent combination of at least a Bachelors level education, training and experience. 2-5 years experience in discharge planning, insurance authorization, and medical terminology preferred. Candidates are required to have a basic understanding of hospital operations and patient treatment planning process, preferably in mental health. Basic understanding of medical necessity criteria for continued stay desired. Computer skills required. Certifications required by department: AHA BLS and SAMA certification annually.

Experience:

2-5 years experience in discharge planning, insurance authorization, and medical terminology preferred. One year of experience in a healthcare setting required.

Licenses/Certificates:

Medical field licensure or certification such as RN/LPN/CTRS required. Current AHA-BLS and SAMA certified. If not SAMA certified must acquire it within 90 days of hire.

Skills:

Basic understanding of medical necessity criteria for continued stay is desired. Knowledge and usage of appropriate computer software and data entry preferred to include Google Suite, AS400, Medhost, Cerner, Mbat-Avelead, etc.

Keywords: Community Health Systems, Cleveland , Utilization Review / Case Management Specialist, Executive , Cleveland, Tennessee

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