Posted on Oct. 3, 2017
San Marcos Treatment Center has an excellent career opportunity for an experienced UTILIZATION REVIEW SPECIALIST / CLINICAL CARE MANAGEMENT COORDINATOR to join our dedicated clinical team, providing services to short-term commercial managed care, Medicaid/State Agency and Tricare-funded patients ages 7-18 with psychiatric, neuropsychiatric or neurodevelopmental issues and their families.
The Clinical Care Management Coordinator understands and navigates LOCAT criteria utilized by managed care. Conducts utilization reviews; complies clinical reports and demonstrates success securing continued coverage/authorization for patients. Prepares and submits appeals of denials. Demonstrates an ability to organize and efficiently implement all service as required in the areas of concurrent and retrospective reviews on open and closed cases and responds appropriate and effectively to exceptional and unusual/non-routine occurrences as they arise.
1. Demonstrate knowledge of payor requirements related to Utilization Review and medical records.
2. Identify record deficiencies based on payor requirements prior to releasing records to reviewing entity / payor.
3. Notify staff as needed to assure required documents and timelines are met.
4. Notify supervisors of problematic patterns and trends regarding record review.
5. Provide copy of all certifications to patient accounts.
6. Actively participate in Level of Care meetings and problem solving meetings.
7. Provide accurate written denial/appeal report for Level of Care meetings.
8. Work cooperatively with patient accounting, admissions, clinicians and other departments to assure efficient use of resources.
9. Monitor and maintain accurate and up-to-date database of all reimbursement denials and appeal status.
10. Demonstrate knowledge of appeal procedure by various payors and/or obtain protocol from payors.
11. Notify clinicians, patient accounting and supervisory staff of all denials within 1 day of receipt.
12. Assure no technical denials are given due to late UR submission of CSRs or required documents.
13. Produce accurate monthly summary of UR activities and PI monitoring.
14. Assist supervisor in monitoring and identifying patterns of care and quality of medical record documentation.