Hybrid Behav Health Utilization Mgmt Coord en Hurley Medical Center

1. Performs concurrent and retrospective review including monitoring the documentation of the ongoing assessment, treatment, and intervention of patients in the behavioral health complex
2. Communicates with the clinical team and providers to review admissions and continued stays. Ensures all necessary parties are aware of patients not meeting criteria for continued stay.
3. Acts as a liaison between the Behavioral Health clinical team and other hospital departments and services with the goal of ensuring utilization management within this specialty hospital service is appropriate and fiscally responsible. Focuses on treatments, testing, and procedures and communicating promptly when any care plan becomes inappropriate for this level of care and clinical condition.
4. Performs the utilization management for this service in a manner that seeks fiscal wholeness for each case within the specialty hospital service. Works with each payer within the parameters of their system or single case agreement to ensure that HMC is able to collect all possible funds.
5. Utilizes the EMR system efficiently and effectively and provides sufficient and clear documentation of all actions taken. 
6. Completes and monitors patient authorization activities as required by various payers.
7. Utilizes all available tools to complete insurance authorization or referral duties in the most effective and efficient manner. Examples include Epic, Health Nautica, Right Fax, various insurance websites and payer portals, enterprise payer matrix, and any other software or application needed to complete the job successfully. 
8. Ensures timely processing of timelines of third party insurance payers for prior authorizations and medical necessity justification purposes. 
9. Works with Patient Access Department to verify patient information and insurance coverage, updates whenever necessary. 
10. Maintains knowledge of all payer authorization guidelines, changes, and updates in order to maintain the necessary knowledge to obtain approvals for services. This includes compliance with regulatory requirements and ensuring all changes are incorporated into their daily job functions.
11. Analyzes cause for and escalates case issues and unapproved authorizations through the appropriate EMR workflows and by telephone in order to seek resolution and maximum payment for the organization.
12. Consistently works with teammates and leadership to help improve workflows, update processes, and foster a positive work culture. 
13. Performs other job duties as required/ assigned. Utilizes new improvements and/ or technology that relate to the job assignment. Involvement in special projects as needed. 

• Graduation from an accredited School of Nursing 
• Three (3) years of clinical experience as a registered nurse in an acute hospital facility, with at least eighteen (18) months’ experience with behavioral health preferred. Working knowledge of utilization management and/or experience preferred.
• Current knowledge of governing regulations, third party payer utilization, quality mandates, reimbursement requirements, and standards associated with behavioral health utilization review and management.
• Ability to work independently, set priorities, organize work, and make decisions in accordance with established policies and procedures while maintaining flexibility.
• Ability to compile, analyze, and evaluate data and prepare accurate reports from such data.
• Current knowledge of third party payer fraud and abuse regulations. 

NECESSARY SPECIAL QUALIFICATIONS:

• Licensed as a Registered Nurse from the State of Michigan.