Utilization Review Manager - Home Care jobs in New York

POSITION SUMMARY

The Utilization Review Care Manager performs initial, concurrent, and retrospective reviews with various payers. Care managers request appropriate level of care based on NYS LOCADTR and medical necessity.

The Utilization Care Manager partners with several key front-end teams in addition to clinicians to serve as a subject matter expert on complex financial questions. They must have in-depth insurance knowledge and general knowledge of the roles and workflow of stakeholder departments. In all work, a high attention to detail and a respect for integrity and confidentiality is always maintained.

RESPONSIBILITIES

• Maintains thorough knowledge of insurance carriers and third-party administrators and are well versed in the various types of benefit plans including PPOs, HMOs, EPOs, tribal plans, Single Case Agreements, public insurers, unions, EAPs and Cobra.
• Understands and follows all HIPAA and CFR42 requirements.
• Completes initial review, continued stay reviews, and retrospective reviews; provides clinical information after patient discharges.
• Coordinates appeal process with concurrent denials from third party payers within contractual or appropriate time frames, as needed.
• Effectively communicates with multidisciplinary team if there are issues with insurance coverage or authorizations.
• Collaborates with the physicians and clinical team in determining the appropriate level of care using NYS LOCADTR.
• Provides timely communication, documentation, and obtain required signatures in the event of an insurance denial, paying careful attention to follow utilization review workflows.
• Promotes staff development and education through live training initiatives.
• Participates in departmental continuous quality improvement activities and committees.
• Audits caseload daily up to weekly to ensure appropriate insurance, self-pay or out of network information is reflected in each encounter. Conducts a final review of all encounters at the close of the calendar year.
• Performs related duties, as required.

REQUIRED EXPERIENCE AND QUALIFICATIONS

• Bachelor’s degree in a health care or behavioral health specialty and CASAC required.
• Master’s Degree in Social Work, Nursing, Mental Health Counseling, or other behavioral health specialty preferred.
• Knowledge and experience with NYS OASAS LOCADTR
• Minimum of three (3) years clinical experience including case management, utilization management, discharge planning; third party payment systems, appeals and denial processes, preferred.

Job Type: Full-time

Pay: $66,000.00 - $73,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Retirement plan
• Vision insurance

Healthcare setting:

• Inpatient
• Rehabilitation center

Schedule:

• Day shift

Education:

• Bachelor's (Preferred)

Experience:

• case management, utilization management, discharge planning: 3 years (Preferred)
• third party payment systems, appeals and denial processes: 3 years (Preferred)

License/Certification:

• LMSW, LMHC, CASAC, Nursing License or equivalent (Preferred)

Work Location: In person