To proactively monitor and optimize reimbursement from external reviewers/third party payers.
- Conducts admission reviews.
- Conducts concurrent and extended stay reviews.
- Prepares and submits appeals to third party payers.
- Maintains appropriate records of the Utilization Review Department.
- Provides staff in-service training and education.
- Assists with training new staff to the department.
Qualifications at Entry:
Graduate of accredited RN or LVN program and current RN or LVN license; LMFT, Masters degree preferred; excellent telephone usage skills and strong verbal skills; knowledge of health care service delivery systems and third party reimbursement; knowledge of managed care environment; ability to apply and interpret admission and continued stay criteria; understanding of admission and discharge function; familiarity with medical terminology, diagnostic terms and treatment modalities; knowledge of medical record keeping; strong interpersonal, organizational, evaluative, and time management skills; policy interpretation skills; familiarity with applicable standards and regulations; flexibility; attention to detail; able to comprehend psychiatric evaluations, consults, lab results, etc.; responsiveness to deadlines; assertiveness, persistence, and persuasiveness; able to work with minimal direction or supervision.
Current CA RN license, Bachelor of Science in Nursing required/Masters Degree in related field preferred. Must also be able to cope well with stress, have a strong sense of compassion and communicate well with others.