Summary: Facilitates reimbursement through certification and chart documentation. Conducts admission and continued stay reviews based on utilization review criteria. Clarifies diagnoses and medical necessity for continued stay.
FTE Status: Full Time
Responsibilities: Facilitates reimbursement through certification process. Conducts admission and continued stay reviews based on appropriate utilization review criteria. Obtains certifications for urgent and emergent admissions.
Follows and intervenes on open cases, including appeals of denials. Communicates case problems to appropriate level. Facilitates chart documentation. Assesses presence of Severity of Illness/Intensity of Service criteria. Collects data from medical records for quality monitoring, compliance audits, risk management, and clinical outcome reporting.
Participates with case manager and social worker in triad configuration. Refers cases to and consults with case managers and social workers. Refers to and consults with medical staff and other internal staff to facilitate documentation and assure timely discharge. Communicates denial case status to case manager, social worker and attending physician.
Facilitates billing. Communicates with third party payors. Enters authorization and days approved data into financial and clinical information systems to facilitate hospital billing.
Within scope of job, requires critical thinking skills, decisive judgement and the ability to work with minimal supervision. Must be able to work in a fast-paced environment and take appropriate action.
Minimum Required Education: High school diploma or GED.
Minimum Experience: 2 years of direct experience in addictions or behavioral health environment.
Experience working with behavioral health insurance authorizations and referrals.
Bachelor's degree in a relevant field.
LPC, LCSW, LAC, CAC2-3, or eligible for these certifications.
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