UR Coordinator

Job ID
2020-3721
Job Locations
US-CA-Aliso Viejo
Posted Date
1 month ago(10/29/2020 9:06 AM)
Category
Clinical

Overview

Company Summary

If you are searching for a fulfilling place to develop your career and an opportunity to make a difference in helping others, then keep reading on. Here at AAC, we have a progressive culture; we listen to your ideas, value a work/life balance, invest in education, and we foster trust and respect for all individuals. Our exceptional comp and strong benefits include company matching 401K, medical, dental, vision and life insurance. We are looking for our future leaders, who are not only going to fill the qualifications for this job description, but who are going to exceed expectations. Be a part of a team whose mission is to provide quality, compassionate, and innovative care to adults struggling with addiction and co-occurring mental health disorders. Our purpose and passion are to empower patients, their families, and our communities by helping individuals achieve recovery and optimal wellness of the mind, body, and spirit.

 

Job Summary

Coordinates and performs Utilization Review functions; primarily focuses on admission reviews, concurrent reviews.

Responsibilities

Duties and Responsibilities: to include but not limited to the following

  • Performs admission and concurrent case reviews with insurance companies as indicated.
  • Initiates conversations with treatment team to clarify care plan, obtain additional information when questioned by insurance CM and be able to answer clinically appropriate questions from insurance CM.
  • Responsible for completing reviews and authorizations for all IOP referrals for patients transitioning from Sunrise House Inpatient levels to Sunrise House outpatient.
  • Caseload will include a minimum of 60 outpatient cases (PHP and IOP). If assignments include higher levels of care such as RTC, the ratio minimum will be 30 cases/day. Higher severity cases will be referred to a UR Supervisor upon identification.
  • Involved in the treatment planning process to ensure appropriate levels of care including preparation & participation in daily treatment team meetings and providing recommendations to team and/or sharing concerns from the insurance CM to resolve.
  • Initiate appeal process on all appropriate cases to facilitate compensation for services rendered including preparatory discussions with Medical Director and summarizing data to support continued admission.
  • Establish optimum communication between departments and patients regarding patient benefits and approved treatment days (certification), and patient’s rights and responsibilities in cases of denial of payment.
  • Supports and promotes an environment of internal and external Customer Service.
  • Ability to establish strong working relationships with insurance Case Managers to have conversations regarding level of care and treatment that discourage a denial of services. This may include new interventions, securing additional information from the team and/or working collaboratively on a discharge plan.
  • Must demonstrate the ability to utilize platforms required to determine level of care and complete and update the required UR assessments as needed.
  • Discusses any medical/psychiatric concerns with direct Supervisor, Medical Director, and/or CEO if indicated.
  • Promptly furnishes a daily report to share with treatment team members at close of business.
  • Completes and updates data in operating platforms as required for billing.
  • Monitors and manages all email correspondences and encourages all clinical documentation is captured in the EMR.
  • Maintains compliance with AAC policies and procedures and annual competencies
  • Maintains compliance with State regulations and accreditation standards.

Qualifications

Education/Experience:

  • Education background sufficient to demonstrate professional competency in utilization review and quality assurance, as evidenced by an accredited college degree in health administration, social work, or license in nursing.
  • Familiarity with alcohol and substance abuse treatment, state licensure, and national accreditation in health care settings.
  • Experience in all or most of the following: Case Management, SUD Treatment Facility, Utilization Review, Managed Care and Discharge Planning.
  • Understanding of medication protocols, mental health, and chronic medical conditions
  • Working knowledge of ASAM criteria required with understanding of dimensions.
  • Ability to initiate, maintain, and promote good interpersonal relationships.
  • Ability to utilize various sources of data within the medical record during UR processes.
  • Good verbal and written communication skills with the ability to have clinical conversations with insurance Case Managers and/or answer questions related to the patients treatment plan as well as a comprehensive understanding of requirements to support each level of care.
  • Ability to maintain patient confidentiality.
  • Computer Skills
  • Strong critical thinking skills.
  • Experience with Aura preferred.

AAC is committed to principles of equal opportunities for all employees.  The Company will provide reasonable accommodations that are necessary to comply with State and Federal disability discrimination laws.

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