Utilization Review Manager - Home Care jobs in Miami, FL

SUMMARY: The primary responsibility of this position is to implement the organization’s Utilization Review(UR) process to ensure appropriate usage of available resources and to optimize reimbursement for services rendered following patient needs. The UR coordinator monitors the client population daily and regularly checks documentation for compliance with current UR best practices. The Coordinator serves as the primary liaison with payers in matters related to utilization, takes a lead role in organizing and conducting UR, and provides regular reports to facilitate decision-making by senior management. The Coordinator also assists in other key administrative functions such as handling admissions inquiries, orienting new patients and families, verification of benefits, and implementing of the organization’s performance management and improvement process.

PRINCIPAL ACCOUNTABILITIES:

• Implement the UR process following organizational policies and procedures.
• Gather information and contact insurance case managers with accurate reports on clients’ medical information and the level of engagement in treatment.
• Ensure UR function complies with P&P, certification standards, and state/Federal statutes and regulations.
• Maintain a mature and professional manner during phone contacts with payers and in dealing with clients, staff, visitors, and the public.
• Maintain an accurate account of the level of care granted by the insurance companies.
• Maintain the daily information, on the client, is accurate and held to strict confidentiality and HIPPA regulations.
• Participate in the morning staffing meetings.
• Provide adequate and appropriate services consistent with best practices and industry standards.
• Adhere to rules and regulations of the Department of State Health Services, CARF, and all Facility standards. To include at a minimum the following:
  • Facility policies and procedures
  • Client's rights, including the unique needs of the persons, served
  • Client grievance procedures
  • Confidentiality of client-identifying information (42 C.F.R. pt 2; HIPAA)
  • Standards of conduct
  • Emergency and evacuation procedures (incident reporting)
  • Exemplary Customer Service
  • Work with a diverse population of clients/staff

Desired Qualifications:

• Bachelor's degree required
• 2 years of Clinical Behavioral/Mental Health Experience.
• Familiar with standard concepts, practices, and procedures for all ASAM outpatient levels of care
• Knowledge of all continuums of care, including admission assessment and continued stay criteria
• Excellent verbal and written communication skills