Utilization Review Specialist

CenterPointe Hospital of Columbia, located in Columbia, Missouri, is the preferred provider of acute inpatient and outpatient treatment for adolescents, adults and seniors, who have been suffering addiction or mental health challenges.

Our mission is to create a world-class treatment program that sets the standard of excellence in the treatment of behavioral health disorders and addictive diseases.

We aspire to provide a setting where people receive care that enables them to regain hope and direction in a supportive, compassionate environment.

PURPOSE STATEMENT: Proactively monitor utilization of services for patients to optimize reimbursement for the facility.

ESSENTIAL FUNCTIONS: * Act as liaison between managed care organizations and the facility professional clinical staff.

* 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.

* Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.

* 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.

* Conduct quality reviews for medical necessity and services provided.

* Facilitate peer review calls between facility and external organizations.

* Initiate and complete the formal appeal process for denied admissions or continued stay.

* Assist the admissions department with pre-certifications of care.

* Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.

OTHER FUNCTIONS: * Perform other functions and tasks as assigned.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS: * Associate's degree in nursing (LPN or RN) required.

Bachelor's or Master's degree in social work, behavioral or mental health, nursing or other related health field preferred.

* Two or more years' experience with the population of the facility and previous experience in utilization management preferred.

LICENSES/DESIGNATIONS/CERTIFICATIONS: * Current licensure as an LPN or RN 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.

* CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.

* First aid may be required based on state or facility requirements.

SHIFT: * Monday - Friday from 8 a.m.

to 5:00 p.m.

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws.

For further information, please review the Know Your Rights notice from the Department of Labor.

null