*All positions are located in Fresno/Clovis CA*
Community Medical Centers has been providing central California with the highest level of care available in the region. Community Regional Medical Center measures up with top hospitals nationally and is the 3rd largest in California! With 685 beds, we are home to the only comprehensive Burn and Level I Trauma center between Los Angeles and Sacramento. The 56,000 square-foot emergency department is one of the largest and busiest in California! We have an 84-bed Level III NICU and plan to significantly expand pediatric specialty care. Our hospital serves 2.5 million people within 9 counties, averaging a daily census of 641 patients. We're affiliated with UCSF as a teaching facility; trained 3,000 Medical Doctor's to date plus continuous invests in research and training grants.
The Behavioral HealthUtilization Review Coordinator is responsible for various aspects of utilization management to ensure that care is rendered in accordance with intensity of service and severity of illness standards at all times during the stay. Works collaboratively with the Case Management team, other departments, and physicians to facilitate efficient and appropriate management of all cases.
Accountabilities
1. Reviews the patient care plan of patients who are under treatment for emotional or mental illness to ensure proper utilization of treatment resources.
2. Processes patient authorizations, denials and appeals.
3. Performs prospective, concurrent and retrospective reviews to determine medical necessity and submits clinical patient information to obtain approval of days and ensure reimbursement for continued inpatient psychiatric treatment according to federal, state and county regulations.
4. Identifies documentation deficiencies, admission screening issues, physician practice patterns, case management, and intensity of service issues contributing to payment denials.
5. Issues denial letters in accordance with policies, procedures and regulatory guidelines. Informs client and/or responsible party of right to appeal and the appeal process.
6. Monitors the length of stay and costs associated per case. Monitors financial aspect of utilization and retrospective review.
7. Responsible for analysis and reporting of utilization data (denial, reimbursement, Potentially Avoidable days).
8. Collaborates with physicians, Case Management and other teams as needed to expedite timely resolution of situations to include, inappropriate admissions, intensity of service issues and with questions regarding appropriate utilization management.
9. Performs other job-related duties as assigned.
Education
• Bachelor's Degree in Social Work (BSW) or related field required
• Master's Degree in Social Work (MSW) or related field preferred
Experience
• 2 years of experience in Discharge Planning, Case Management or Utilization Management required
• Experience in the Utilization Review process and insurances preferred
• Experience in a Behavioral Health environment is preferred
• Pay ranges listed are an estimate and subject to change.
• If any bonuses are noted, they are only applicable to external hires meeting criteria.
Address
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