Position Summary: Responsible for proactively monitoring the utilization of continuum services and optimize reimbursement for the system. Reviews clinical documentation on each patient and works directly with managed care or insurance companies/entities performing concurrent, live reviews with provided clinical documentation to get additional patient days authorized for payment as needed. Communicates with the inter-disciplinary team members to ensure optimal length of stay for patients depending on their continued medical necessity for treatment or care; reviews and provides feedback to the Medical Director, psychiatrists, DON and clinical leaders as to quality of documentation to support continued medical necessity

Essential Functions:

• Develops and maintains effective working relationship with all disciplines
• Advise treatment team when clinical criteria have been inadequately documented
• Obtains additional information from Medical, Nursing, and Social Services as needed to determine medical necessity for continued stay
• Manages workload in an effective manner
• Obtain daily clinical documentation to assess for accuracy and completeness
• Organizes information daily for each case to be presented to Third party payers for continued authorization.
• Conducts concurrent reviews daily
• Files Appeals for denials as indicated.
• Evaluates information in patient record for medical necessity of continued stay at current level of treatment
• Assimilates all clinical information into a concise, cogent product.
• Completes all needed case reviews and needed follow up daily
• Completes all data entry of review results in the client information system daily
• Completes all data entry of review results in Approval /Denial Log daily
• Communicates effectively with managed care and referral sources.
• Maintains positive working and collaborative relationships with insurance and managed care providers.
• All other duties as assigned

Minimum Qualifications:

Education: Associate’s Degree or higher preferred in: Nursing, social work, psychology, health information management or other healthcare field is preferred, or related experience. May substitute Degree with High School Diploma with minimum of 4 years Psychiatric/Mental/Behavioral Health Experience.

Experience: Experience in a psychiatric setting, knowledge of health care service delivery systems, and third-party reimbursement preferred; knowledge of managed care environment.