• Manages and performs utilization reviews to ensure adherence to federal regulations and payer requirements
• Assists in maintaining records, answering correspondence and preparing and disseminating reports.
• Familiar with treatment concepts, practices and facility procedures that impact patient care
• Applies approved medical necessity criteria towards conducting admission and continued stay record reviews
• Acts as liaison with third party payers, managed care companies and billing company around communication specific to authorizations for approved patient admissions, continued stay, discharge planning and aftercare.
• Completes all utilization reviews for Detox, Residential, PHP, IOP and Community IOP levels of care.
• Sends out admission notifications when assessments are complete.
• Answers any questions regarding scheduling, etc.
• Obtains approval for alternative levels of care.
• Ensures that insurance companys specific questions are addressed in Utilization review interactions may require communication with clinicians and providers.
• Communicates denials or possible denials with treatment team to coordinate discharge plan.
• Requires after hours communication (text, email) with Chief Executive Officer, facility financial representatives or billing company when admission nursing assessment is complete.
• Occasionally provides information that billing company may send to appropriate parties.
• Adhere to all confidentiality laws and maintain ethical, professional boundaries with clients.
• Active participant in performance improvement and quality assurance initiatives that relate to documentation, specific payer initiatives and any payer-initiated action plans to improve facility performance
• Communicates any concerns relating to documentation and patient care needs to the appropriate departmental leader based on review of patient charts.
• Active participant of facility treatment team meetings
• Applies knowledge of managed care, pre-certification, concurrent reviews, medical/psychiatric diagnoses, medications and insurance payment practices.
• Helps with any other related activities or duties that are required.

• High School diploma or equivalent
• 3+ years' experience in healthcare setting
• Must pass State of Florida criminal background and driving record checks

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