The Clinical Utilization Reviewer - Registered Nurse/Licensed Clinician – collects, analyzes, and provides pertinent, timely clinical information including medications, to payer sources and external utilization review personnel for authorization of inpatient stay and services of the initial, concurrent, and discharge authorizations and reviews which are completed through interactions with the client's insurance companies during normal business hours including, nights, weekend and holidays as necessary.
ESSENTIAL DUTIES AND RESPONSIBILITIES
· Obtain proper authorization for each admitted patient.
· Review and monitor each step of the authorization process to proactively identify and resolve problems.
· Interact with physicians and therapists on an on-going basis to assure patient assessment and treatment planning are appropriately coordinated to gather all clinical information to determine the medical necessity of requested healthcare per the ASAM criteria.
· Assure services are accurately and consistently reflected in facility documentation.
· Maintain a daily record in the Electronic Health Record (EHR) system of the concurrent review process and inform the treatment team of the authorization status of each assigned patient.
· Help patients access the full range of their benefits through creative utilization.
· Work to extend patients treatment stay as needed or deemed medically appropriate through maximization of benefits and minimizing appeals.
· Assess each patient's individual needs based on assessment and data collection to ensure proper admission.
· Implement doctor's orders, administer specified medication, monitor, and record vital signs, and maintain medical/ nursing records.
· Utilize the Electronic Health Record system effectively and efficiently.
· Coordinate and direct duties of Registered Nurses (RN/LPN or Medical Assistants-MA's), Recovery Support Staff (RSS) and (Licensed) Chemical Dependency Professionals (L/CDP) to achieve optimum treatment effectiveness, efficiencies, quality of care and overall improvement.
· Provide training to staff to achieve treatment and utilization integrative goals.
· Observe patients and document their responses to treatment.
· Communicate with Medical and L/CDP staff on a regular basis regarding patient's progress and treatment plans.
· Discharge patients in accordance with established policy.
· Carry out administrative procedures in compliance with program policies.
· Ensure program compliance with all CARF, DEA, DOH, BHDDH, local, state, and federal regulations and licensing requirements.
· Participate in and/or facilitate staff meetings, treatment team/case conference meetings, and required trainings, as assigned, to ensure continuum and quality of care regarding patient treatment and agency issues.
· Complete all reviews including initial, concurrent and discharge with insurance company and input the authorizations into the Electronic Health Record system according to compliance.
· Serve as a rolemodel through positive, appropriate conduct and participation in special agency events. Project a good image to the public and actively participate in community/State meetings.
· Maintain DATIS files and complete Relias E-learning requirements in a timely fashion.
· Meet with supervisor on a regular basis.
· Perform other duties as assigned by the Assistant Vice President or other Senior Executive. This is not intended to be a complete list of all duties and expectations. Obtain proper authorization for each admitted patient.
· Demonstrate empathy and compassion for patients and staff in all daily interactions.
· Proficiency with CPT coding.
· Overall typing accuracy and proficiency in using Phoenix House systems, including the EHR system to document notes and activities as required.
· Proficiency with insurance verification and authorizations.
· Demonstrate appropriate boundaries between self and patients.
· Demonstrate patience and consideration in dealing with others.
· Demonstrate thoughtful decision-making.
· Work cooperatively with others and supervisors.
· Ensure patient confidentiality in accordance with all federal, state, and local laws and regulations.
· Ability to promote and demonstrate “Every Time Behaviors” Teamwork model.
· Ability to promote and demonstrate Phoenix House's ICARE4 core values (Integrity, Collaboration, Accountability, Respect, Excellence, Forward Thinking) through work ethic, compliance, and attitude:
- Willingness to Help
KNOWLEDGE, SKILLS & ABILITIES
To perform this position successfully, you must be able to perform each essential duty and responsibility satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties and responsibilities. The requirements listed below are representative of the knowledge, skill and/or ability required.
· Knowledge obtained through attainment of applicable state Registered Nurse's license and/or Clinical Mental Health license.
· Extensive knowledge of the daily operations of a not-for-profit substance use and mental health disorder treatment facility.
· Knowledge of Continuous Quality Improvement process and Performance Improvement program design, tracking and implementation
· Knowledge of rules/regulations and ability to comply with all state and federal regulations, including confidentiality (HIPAA, 42 CFR Part II and Employee Records and all other confidential materials).
· Skill in implementing nursing protocol.
· Skill in patient assessment.
· Skill in performing and/or managing tasks and/or people to ensure program and policy administration.
· Skill in representing the organization internally and externally.
· Strong communication, documentation, clinical and critical thinking skills essential.
· Strong working knowledge of the clinical utilization review process.
· Ability to assign, direct, coordinate and collaboratively work independently and as a team.
· Ability to carry out instruction and accurately document medical information.
· Ability to perform the core functions of a substance use and mental health disorder professional.
· Ability to develop rapport with populations and families suffering from substance use and mental health disorder.
· Ability to prioritize conflicting demands/expectations as well as to multi-task effectively for sustained periods of time.
· Ability to measure effectiveness of clinical services provided and makes corrective actions / improvements.
· Ability to apply organizational and time management to meet competing deadlines.
· Ability to collaborate and build successful relationships with others to ensure objectives and goals are met.
· Ability to apply organizational management skills and maintain self-discipline.
· The ability to be forthcoming with information and/or personal challenges to ensure the facility Vice Presidents have an accurate awareness of any issues that may impact him/her or his/her program as well as his/her staff or other members of Phoenix House.
· Proficiency in operating software programs to type documents, manage databases, presentations and create spreadsheets.
· Communication skills both written and verbal as well as the understanding of the principals of communication in multiple directions, vertically, horizontally, and laterally.
· Problem solving skills with a “solution oriented” mind-set.
· Accountable and Dependable.
Nursing and/or Mental Health Clinician degree from an accredited institution or equivalent combination of knowledge and experience.
Valid RI Registered Nurse license, Licensed Mental Health Clinician and/or Masters Degree (Licensed Eligible)
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties and responsibilities of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties and responsibilities.
REGULARLY REQUIRED: to sit, use hands to finger, handle or feel objects, tools, or controls; reach with hands and arms, and talk or hear.
OCCASIONALLY REQUIRED: to stand, walk, stoop, kneel or crouch and lift and/or move up to 10 pounds
The work environment characteristics described here are representative of those an employee encounters while performing the essential duties and responsibilities of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties and responsibilities.
The work environment is that of a substance abuse treatment milieu which may include:
§ Exposure to patients infected with Hepatitis B, HIV, TB, or other Infectious Diseases (e.g. Flu, COVID-19, etc.)
§ Exposure to patients with co-occurring mental health issues.
§ Weekend and holiday hours
§ Business-related travel as needed
Monday – Friday, 8:00 am – 5:00 pm unless otherwise specified.
Occasional evening and/or weekend work needed.
Phoenix House is an Equal Opportunity Employer providing equality of opportunity to all who are protected against discrimination by law, regulation or executive order, including veterans and individuals with disabilities. EEO is the Law: Applicants and employees are protected under Federal law from discrimination. Click www.dol.gov/ofccp/regs/compliance/posters/pdf/eeopost.pdf to learn more.