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About the position
The position serves as a liaison between managed care organizations and the facility's professional clinical staff. The role involves conducting reviews in accordance with certification requirements for insurance plans or other managed care organizations (MCOs) and coordinating communication regarding reimbursement requirements. The individual will monitor patient length of stay and extensions, informing clinical and medical staff about issues that may impact these metrics. Additionally, the position requires gathering and developing statistical and narrative information to report on utilization, non-certified days, discharges, and quality of services as required by facility leadership or the corporate office. Quality reviews for medical necessity and services provided will also be conducted, along with facilitating peer review calls between the facility and external organizations. The individual will initiate and complete the formal appeal process for denied admissions or continued stays and assist the admissions department with pre-certifications of care. Ongoing support and training for staff on documentation or charting requirements, continued stay criteria, and medical necessity updates will be provided.
Responsibilities
- Act as liaison between managed care organizations and the facility professional clinical staff.
- Conduct reviews of insurance plans or other managed care organizations (MCOs) and coordinate communication concerning reimbursement requirements.
- Monitor patient length of stay and extensions, informing 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, discharges, and quality of services as required by 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.
Requirements
- Associate's degree in nursing (LPN or RN) required.
- Two or more years' experience with the population of the facility and previous experience in utilization management preferred.
Nice-to-haves
- Bachelor's or Master's degree in social work, behavioral or mental health, nursing or other related health field preferred.
