Position Highlights:

• Position: Utilization Review Coord

• Location: LOH- Warrenville Corp Center

• Full Time

• Hours: Monday-Friday,7:30-4:00pm

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A Brief Overview:
Under supervision, coordinates the utilization management program for Linden Oaks Hospital which involves pre-certification of care and concurrent reviews for continued care stays with a high degree of collaboration with clinical therapist and other patient care staff required. Provides comprehensive orientation and on-going education to staff on topics of utilization review and utilization management. All duties are performed as delineated by licensure and/or experience.

What you will do:

• Serves as utilization coordinator and advocate for assigned patients.

• Monitors admissions to assure accurate pre-certification to all levels of care.

• Monitors patient’s health plan benefits and takes into consideration previous episodes of care whether at Linden Oaks or another facility, the current episode of care as well as anticipated future clinical care.

• Pursues pre authorization and concurrent review authorization for appropriate level of care on a timely basis.

• Coordinates clinical and financial follow up with financial counselors, case managers and physicians.

• Coordinates insurance company physician reviews with Linden Oaks physician reviews (ie., Doc to Doc’s, Shaping Reviews) and, at times, may complete review on behalf of attending psychiatrist.

• Documents review in Epic system.

• Monitors length of stay and any other required clinical and financial services.

• Attends treatment team meetings and care conferences in programs as assigned.

• Assures compliance with hospital contract requirements with managed care, Medicare, Medicaid.

• Issues denials for Medicare beneficiaries who are not meeting medical necessity criteria and follows hospital policies for reporting denials to regulatory agency.

• Meets with insurance company representatives to discuss various trends at Linden Oaks in the industry, as needed.

• Provides education to staff and physicians on topics of utilization review and contract requirements. At times, may be required to present in front of a larger group on these topics.

• Completes insurance appeals, whether via telephone or formal letter on a timely basis.

• Develops systems that minimize concurrent and retroactive denials and reports activity on a monthly basis.

• Follows up with insurance companies at all appeal levels until all appeal levels are exhausted.

• Documents in Epic on patient account the level of the appeal.

• Assures quality improvement by interpreting statistical data on utilization management and review and assists in the implementation of procedural changes based on patient needs. Coordinates with treatment team when documentation does not support medical necessity and educates treatment team on appropriate documentation.

• Participates in the analysis of data and recommends solutions for improving care and outcomes. Actively participates on quality improvement initiatives to improve patient care, efficiently manage clinical resources, and otherwise ensure financial viability of the product line. Develops standards and policies and procedures that reflect current professional guidelines and promotes staff compliance with standards.

• Serves as a consultant to staff in solving complex patient or system problems and facilities and ensures effective communication and consensus within the healthcare team, as delineated by licensure and/or experience.

• Demonstrates conduct in keeping with the EHSC “We Will” statements.

What you will need:

Required Education and/or Experience:

•  Master’s Degree in a healthcare related field or a Registered Nurse

• Knowledge of DSM IVR (Diagnostic and Statistical Manual of Mental Disorders) diagnostic criteria

Preferred Education and/or Experience:

• Minimum one year of previous utilization review experience

• Familiarity with continuum of care and assessment, intervention skills, managed care, Medicare, Medicaid, and other third-party reimbursement

Required License and/or Certification:

• Current state of Illinois Registered Nurse licensure, if RN

Preferred License and/or Certification:

• Current state licensure such as LCPC (Licensed Clinical Professional Counselor),  LCSW (Licensed Clinical Social Worker), LPC (Licensed Professional Counselor)or LSW(Licensed Social Worker)

Benefits:

• Career Pathways to Promote Professional Growth and Development

• Various Medical, Dental, and Vision options

• Tuition Reimbursement

• Free Parking at designated locations

• Wellness Program Savings Plan

• Health Savings Account Options

• Retirement Options with Company Match

• Paid Time Off and Holiday Pay

• Community Involvement Opportunities