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Company Name : Peak View Behavioral Health
Location : Colorado Springs, CO 80923
Position : Utilization Review Specialist
Job Description : POSITION SUMMARYThe Utilization Review Specialist is responsible for reviewing of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria which meets the daily deadlines to obtain authorizations and complete other pertinent processes.QUALIFICATIONSEducation/Licensure: Bachelor’s degree from an accredited college or university in social work, mental health or a related field, or a nurse with mental health related experience.Experience: One (1) year experience with communication with external review organizations or comparable entities and direct clinical experience in a psychiatric or mental health setting is preferred.Experience with insurance authorizations, medical records and medical terminology experience preferred.Additional Requirements: Completion of CPR/AED course and Handle with Care training, including appropriate and safe use of seclusion and restraint, within 30 days of employment and timely renewal.Note: In support of PVBH’s quality requirements, we require a post-offer drug screen, physical, criminal background review and conduct original source verification of degrees/certifications of all candidates.STANDARDS OF PERFORMANCEDEPARTMENTAL RESPONSIBILITIES1. Perform admission, concurrent, continued stay, and retrospective reviews using the established hospital criteria. Communicate effectively with managed care organizations. Provide information they need in a logical, concise manner using technical language that accurately describes patient’s condition and need for hospitalization.2. Daily, communicate effectively with co-workers, program, and nursing staff regarding charting deficiencies and problems identified. Follow up in each instance to determine if corrective action was taken. Notify supervisor if corrective action not completed.3. Regularly check for properly signed consents prior to discussing cases with others. Ensure patient confidentiality.4. Coordinate information and findings with the business office to help recognize or resolve possible payment problems.5. Follow hospital Utilization Review Plan and refer problem cases to U.R. Manager, then follow through to problem resolution and communication daily.6. Maintain Utilization Review files in a neat, orderly, and confidential manner with special attention to security.7. Assist with any problems encountered during on-site or telephone reviews by the third-party payers or review organization, when necessary.8. Effectively communicate with physicians regarding documentation or assistance needed.9. Investigate short term length of stays and endeavor to create alternate financial planning which would offer the patient extended days of treatment. Participate in discharge planning as required.10. Independently schedule the completion of reviews, so that there is a continuum of reviews, as per plan.11. Appeal all denials ensuring accuracy of information and effective coordination of correspondence.12. Attend all treatment team meetings. Interface with treatment team to offer suggestions to improve documentation.DEPENDABILITY/INITIATIVE1. Functions as a role model for other department and facility staff.2. Supports facility-wide quality/performance improvement goals and objectives.3. Participates in Performance Improvement activities, as assigned, and is responsible for the effectiveness of the Performance Improvement program as it pertains to Utilization Review.4. Demonstrate ability to orchestrate a myriad of activities and to manage multiple priorities within complex and changing systems.5. Assist with evaluation of program goals and objectives on a regular basis.6. Supports the mission, vision, and values of Peak View Behavioral Health.7. Adhere to facility standards concerning conduct, dress, attendance and punctuality.8. Use time constructively and in an organized manner to accomplish assigned responsibilities.9. Adheres to department call in procedure.10. Complete appropriate process to request time off adhering to department standards.11. Report to work as scheduled.EDUCATION DEVELOPMENT1. Attend all mandatory facility in-services and staff development activities as scheduled.2. Completes annual updating of competency file.3. Identify personal learning needs to assist with staff development and assist with planning and teaching staff development programs, as assigned.HOSPITAL POLICIES AND PROCEDURES1. Serve on Facility Committees as assigned.2. Wears hospital issued name badge at all times.3. Ensure that personal performance meets TJC, CMS and state regulatory requirements.4. Ensure that all deficiencies identified through the Performance Improvement plan are corrected with appropriate problem-solving actions.5. Adhere to facility standards concerning conduct, dress, attendance and punctuality.6. Maintain confidentiality of facility employees and patient information.7. Comply with established measures for infection control, OSHA regulations, and risk management.8. Comply with all facility policies and procedures related to ethical practices and conduct.9. Adhere to all facility and personnel policies and procedures.10. Ensure timely renewal of all job requirements, i.e., licensure, CPR, CPI, TB screening, etc.SAFETY MANAGEMENT1. Practice standard precautions and environmental safety guidelines.2. Follow/implement all safety policies and procedures during actual or staged safety emergencies (fire, tornado, disaster, etc.).3. Adhere to all facility safety management policies, including maintaining compliance with environment of care modules.4. Ensure that the physical environment of the area is monitored for safety, cleanliness, and attractive appearance and all deficiencies are corrected in a timely manner.COMMUNICATIONS/RELATIONS WITH OTHERS1. Demonstrate effective and professional oral and written communication skills.2. Demonstrate a professional attitude and support the objectives of the Facility’s marketing and guest relations philosophy through internal and external communications and interactions with all levels of staff, patient’s family members, guest, community and referral sources.3. Adjust communication to reflect age specific growth and development needs.4. Address clients, visitors, and co-workers in a pleasant and respectful manner.5. Facilitate and coordinate the channels of communication between patient/families and management.CULTURAL/SPIRITUAL DIVERSITY1. Demonstrate an awareness of differences in communication styles and cultural and spiritual values and work ethics.2. Demonstrate an ability to refrain from assuming that everyone is “just like me” or judging others by one’s own codes of behavior.3. Demonstrate an understanding of how cultural rules of behavior impacts how we perceive others and how they perceive us. Demonstrate a willingness to modify behavior accordingly.4. Demonstrate an ability to identify instances where one’s own cultural, ethnic bias impact decision-making and behavior and makes an effort to reduce these occurrences.5. Demonstrate application of appropriate and respectful behavior toward patients and staff different from oneself.COMPETENCY, KNOWLEDGE, PRODUCTIVITY, SKILLS, AND ABILITIESTHIS SECTION DESCRIBES WHAT KNOWLEDGE, SKILLS AND ABILITIES AN EMPLOYEE IN THIS POSITION SHOULD CURRENTLY POSSESS. THIS LIST MAY NOT BE COMPLETE FOR ALL KNOWLEDGE, SKILLS AND ABILITIES REQUIRED FOR THIS POSITION.1. Knowledge of utilization review procedures2. Knowledge of external review organizations (i.e. managed care, Medicare, Medicaid, state gate keeper for Medicaid)3. Knowledge of patients’ rights, advanced directives, adult and child abuse laws, and emergency detention4. Knowledge and utilization of crisis intervention techniques5. Knowledge of payer resources and financial planning6. Excellent leadership and negotiation skills7. Excellent customer relation’s skills8. Excellent organizational and interpersonal communication skills9. Skill in interacting with multiple individuals with diversified roles and perspectives10. Skill in organizing and prioritizing workloads to meet deadlines11. Skill in telephone etiquette and paging procedures12. Effective oral and written communication skills13. Ability to communicate effectively both verbally and in writing14. Ability to handle conflicting situations15. Ability to focus on details in a busy environment16. Ability to operate in an unstructured environment, orchestrate a myriad of activities and to manage multiple priorities within complex systems17. Ability to tolerate ambiguity, uncertainty, and change18. Ability to work at a rapid pace19. Ability to communicate effectively with patients and co-workers20. Ability to adhere to safety policies and procedures21. Ability to use good judgment and to maintain confidentiality of information22. Ability to work as a team player23. Ability to demonstrate tact, resourcefulness, patience and dedication24. Ability to accept direction and adhere to policies and procedures25. Ability to recognize the importance of adapting to the various patient age groups (adolescent, adult and geriatric)26. Ability to work in a fast-paced environment27. Ability to meet corporate deadlines28. Ability to react calmly and effectively in emergency situations29. Ability to locate a chart in HIMPeak View Behavioral Health provides equal employment opportunities to all applicants without regard to race, color, religion, gender, sexual orientation, gender identity or expression.Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served. Job Type: Full-timePay: From $23.50 per hourBenefits:401(k)Dental insuranceEmployee assistance programEmployee discountHealth insuranceLife insurancePaid time offTuition reimbursementVision insuranceSchedule:8 hour shiftMonday to FridayExperience:Utilization review: 1 year (Preferred)License/Certification:RN (Preferred)Work Location: One location
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