St. Clare's - Boonton - Boonton, NJ
posted 20 days ago
Full-time - Mid Level
Boonton, NJ
About the position
The Utilization Review Coordinator at Saint Clare's Health is responsible for managing the quality and resource allocation for patients admitted to inpatient behavioral health units. This role involves coordinating with external case managers and managed care organizations to ensure pre-authorization and concurrent reviews, while also assisting the treatment planning team with insurance requirements and compliance audits. The position aims to facilitate quality, clinical, and cost-effective outcomes throughout the patient's stay.
Responsibilities
- Manage quality and resource allocation for patients in inpatient behavioral health units.
- Contact external case managers and managed care organizations for pre-authorization and concurrent reviews.
- Assist in appeals and denials management during the patient's stay.
- Support the treatment planning team with insurance requirements and complete UR audits for billing compliance.
- Conduct holistic and comprehensive admission and concurrent reviews of medical records for medical necessity and service intensity.
Requirements
- Bachelor's degree in Social Work, Psychology, or a related health field.
- Knowledge of DSM 5 diagnosis and medical necessity criteria for behavioral health levels of care.
- Familiarity with basic psychological and medical terminology.
Nice-to-haves
- Master's degree in Social Work, Psychology, or a related health field is highly preferred.
- One year of experience in direct care (inpatient or outpatient) mental health, case management, discharge planning, or nursing management is preferred.
