The Utilization Review Specialist at Rebound Behavioral Health will be responsible for conducting initial and concurrent reviews while reviewing clinical documentation for the stay of the patient. Rebound Behavioral Health is located in Lancaster, SC and serves the adult patient population who are experiencing an acute behavioral and/or mental health crisis. In the Utilization Review department team members work closely with the nursing, clinical services and providers to ensure the appropriate stay for patients and solid documentation. The position is part-time, 20 hours/week.
Essential Functions, include but not limited to:
* Act as liaison between managed care organizations and the facility professional clinical staff.
* Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
* Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
* Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
* Conduct quality reviews for medical necessity and services provided.
* Facilitate peer review calls between facility and external organizations. Initiate and complete the formal appeal process for denied admissions or continued stay.
* Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.
Educational/Skills/Licensure/Experience Requirements:
* Associate's degree in nursing (LPN or RN) required. Bachelor's or Master's degree in social work, behavioral or mental health, nursing or other related health field preferred.
* Two or more years' experience with the population of the facility and previous experience in utilization management preferred.
* Current licensure as an LPN or RN within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.
* CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.
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