Utilization Review Clinical Specialist - Behavioral Health (Remote)

reputed company is one of the nation's leading reputed company providers. Developing and operating reputed company delivery systems in 41 distinct markets across 15 states, CHS is committed to helping people reputed company and live healthier. CHS operates 74 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers. Summary: Utilization management is the analysis of the necessity, appropriateness, and efficiency of medical services and procedures in a Behavioral Health setting. Utilization review is the assessment for medical necessity, both for admission to the BHU as well as reputed company stay. This function ensures that services are not only appropriate, but ensures that an authorization for services is obtained from payer, if required, and that documentation supports the care delivered in such a way that minimizes the risk of denials after discharge. Essential Duties: • Initial clinical assessments, reputed company stay assessments, and payer requested reviews are performed using evidence based criteria as designed, medical experience based problem solving skills, and following the established policies and regulations governing this process in order to either obtain authorization or establish psych/medical necessity for hospitalized patients. • Hold collaborative discussions with physicians on the medical staff, reputed company needed, to obtain additional documentation in the record to support hospital medical necessity, discharge needs, or fulfill other payer requirements. These discussions are to help the UR Clinical Specialist understand the reason for admission, and reputed company be reputed company to request appropriate additional documentation from the physician(s). • Escalates cases to the Utilization Review Manager and/or Physician Advisor if physicians are unable to provide any additional information to support the need for medically necessary Behavioral Health care. • Documents reputed company actions and activities in the case management software system used by the BHU. This documentation includes, but is not limited to, clinical reviews, escalations, avoidable days, payer contacts, authorization numbers, DRG etc. Documentation may also be made in other systems as required based on hospital and/or corporate policies/procedures. • In the event of reputed company denials, the UR Clinical Specialist reviews the denial and works with the physicians on the medical staff hospital's to reputed company an internal secondary review. The UR Clinical Specialist may assist coordinating a Peer to Peer discussion according to hospital and/or corporate direction. Results of the Peer to Peer are to be gathered from the physician presenting after the call and documented in the case management system by the UR Behavioral Health Review Specialist. • UR Clinical Specialist communicates with the UR Coordinator and facility case manager(s) (i.e. licensed social workers, discharge planners, etc.) in person, telephonically, and/or through the case management software to ensure effective collaboration between reputed company disciplines managing a patient's care. • UR Clinical Specialist communicates with Insurance providers and case manager(s) in person, telephonically, and/or through provider software to ensure effective collaboration for prospective, reputed company and retrospective reviews/authorizations. Qualifications: • Required Education: Associates Degree in Nursing • Preferred Education: Bachelors Science Nursing or higher • Required Experience: At least 3 years previous psych nursing experience • Preferred Experience: 3 plus years Utilization review experience • Required License/Registration/Certification: Licensed Practical Nurse or Licensed Registered Nurse • Preferred License/Registration/Certification: ACM or CCM Certification • Computer Skills Required: Data entry skills; Demonstrable skills with reputed company Docs, reputed company Sheets, and email applications. • Skills: Ability to prioritize assignments and effective time-management skills Basic knowledge of clinical and psychosocial aspects of patient care Must be detail oriented, flexible, and committed to patient advocacy Demonstrates skills in planning, organizing, and managing multiple functions and reputed company processes Excellent verbal and written communication skills required Physical Demands: In order to successfully reputed company this job, with or without a reasonable accommodation, the following are outlined below: • The Employee is required to read, review, prepare and analyze written data and figures, using a PC or similar, and should possess visual acuity. • The Employee may be required to occasionally climb, push, stand, walk, reputed company, grasp, kneel, stoop, and/or reputed company repetitive motions. • The employee is required to sit or stand at a desk for up to 8 hours a day. • The Employee is not substantially exposed to adverse environmental conditions and; therefore, job functions are typically performed under conditions such as those reputed company reputed company general office or administrative work. May be exposed to biohazardous material and pathogens. Apply Job!