Utilization Specialist Job at Acadia Healthcare (Scotts Valley)

Utilization Review Specialist - PRN

San Jose Behavioral Health is currently seeking a Utilization Review Specialist ...

Location

United States , San Jose

Salary:

33.00 - 60.00 USD / Hour

Acadia Healthcare

Expiration Date

Until further notice

Requirements

Associate Degree in Nursing(LPN/LVN/RN) Required
Two or more year's experience with the population of the facility preferred
Previous experience in utilization management is preferred
LMFT, LMSW, LCSW, LPC, LPC-Iwithin the state where the facility provides services
or current clinical professional license or certification, as required, within the state where the facility provides services
CPR and de-escalation and restraint certification required (training available upon hire and offered by facility)
Bachelors or Masters degree in Social Work, Behavioral Health Or Mental Health, Nursing or Other related health field preferred

Job Responsibility

Coordinate and assess the inpatient census for appropriate alternate health care service needs
Perform on-site and/or telephonic concurrent review of acute and sub-acute services, as well as pre-certification review for all services following the plans authorization guidelines
Coordinate with appropriate discharge planning processes, providing feedback on documentation processes
Function as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options
Act as liaison between managed care organizations and the facility professional clinical staff
Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements
Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay
Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office
Conduct quality reviews for medical necessity and services provided
Facilitate peer review calls between facility and external organizations

Utilization Insurance Specialist

To provide clinical information to Managed Care/Insurance Companies/BHO to demon...

Location

United States , New York

Salary:

65885.00 - 98827.00 USD / Year

Mount Sinai Health System

Expiration Date

Until further notice

Requirements

Master’s Degree Preferred with experience in related field
Experienced in Insurance care management or utilization management

Job Responsibility

Responsible for all aspects of the concurrent review program, insurance certification, and authorization process for all Psychiatric or Chemical Dependency Inpatient Units
Develops rapport with and daily working relations Admitting and Inpatient clinicians to insure ongoing, comprehensive clinical information
Maintains daily communications and documentation with all Hospital Insurance Verification and Patient Accounts staff to insure timely verification of patient insurance and insurance status
Coordinates insurance authorizations through provision of appropriate clinical information
Communicates with inpatient clinical staff to insure timely discharge planning is in place when insurance authorizations expire
Monitors and coordinates the designation of alternative level of care with the UM Manager and/or Program Manager and Physician
Notifies and coordinates inpatient services when delays are noted in order to reduce length of stay and improve quality of care
Responsible for data and report generation of providers as well as regulatory agencies
Demonstrates the knowledge and skills necessary to provide care based on physical, psychosocial, educational, safety, and related criteria
Utilizes Hospital Mainframe programs, CANOPY Care Management System, and TRAC effectively

Fulltime

Utilization Management Nurse Specialist RN II

The Utilization Management Nurse Specialist RN II facilitates, coordinates, and ...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing
At least 5 years of varied RN clinical experience in an acute hospital setting
At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting
Registered Nurse (RN) - Active, current and unrestricted California License
Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint
Provision of excellent customer service
Excellent time management and priority-setting skills
Maintains strict member confidentiality and complies with all HIPAA requirements
Strong verbal and written communication skills

Job Responsibility

Facilitates, coordinates, and approves medically necessary referrals that meet established criteria
Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status
Generates approval, modification and denial communications, to include member and provider notification of referral determination
Actively monitors for admissions in any inpatient setting
Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan
Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review
Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers
Acts as a department resource for medical service requests /referral management and processes
Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps
Follows up with caller to provide response or resolution steps

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Utilization Management Nurse Specialist RN II

The Utilization Management Nurse Specialist RN II facilitates, coordinates, and ...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing
At least 5 years of varied RN clinical experience in an acute hospital setting
At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting
Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint
Excellent time management and priority-setting skills
Strong verbal and written communication skills
Registered Nurse (RN) - Active, current and unrestricted California License

Job Responsibility

Facilitates, coordinates, and approves medically necessary referrals that meet established criteria
Assures timely and accurate determination and notification of referrals and reconsiderations
Generates approval, modification and denial communications
Actively monitors for admissions in any inpatient setting
Performs telephonic and/or onsite admission and concurrent review
Collaborates with onsite staff, physicians, providers, member/family to develop and implement a successful discharge plan
Works with the UM Manager and Physician Advisor on case reviews
Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers
Acts as a department resource for medical service requests /referral management and processes
Receives incoming calls from providers, professionally handles complex calls

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Utilization Management Nurse Specialist RN II

The Utilization Management Nurse Specialist RN II facilitates, coordinates, and ...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing
At least 5 years of varied RN clinical experience in an acute hospital setting
At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting
Registered Nurse (RN) - Active, current and unrestricted California License
Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint
Provision of excellent customer service required
Excellent time management and priority-setting skills
Maintains strict member confidentiality and complies with all HIPAA requirements
Strong verbal and written communication skills

Job Responsibility

Facilitates, coordinates, and approves medically necessary referrals that meet established criteria
Assures timely and accurate determination and notification of referrals and reconsiderations
Generates approval, modification and denial communications
Actively monitors for admissions in any inpatient setting
Performs telephonic and/or onsite admission and concurrent review
Collaborates with onsite staff, physicians, providers, member/family to develop and implement a successful discharge plan
Works with the UM Manager and Physician Advisor on case reviews
Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers
Acts as a department resource for medical service requests /referral management and processes
Receives incoming calls from providers, professionally handles complex calls

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

New

Drug Product Quality Assurance Specialist

In this vital role within the Plant Quality Assurance organization the Drug Prod...

Location

United States , Thousand Oaks

Salary:

104287.35 - 141094.65 USD / Year

Amgen

Expiration Date

Until further notice

Requirements

Doctorate degree OR Master's degree and 2 years of quality experience OR Bachelor's degree and 4 years of quality experience OR Associate's degree and 8 years of quality experience OR High school diploma / GED and 10 years of quality experience

Job Responsibility

Partners with Manufacturing, Facilities & Engineering, Quality Control, and other cross-functional stakeholders to facilitate root cause analyses, risk assessments, CAPAs, and effectiveness verification activities
Participates in and provides quality oversight for quality records including Deviations, Change Controls, and CAPAs, assuring adherence to procedural requirements and regulatory expectations
Partners with our colleagues in Manufacturing, Supply Chain, Facilities and Engineering and Automation to maintain our strong culture of Quality and Safety and ensure we continue to meet Amgen standards
Provides Quality Oversight of the manufacturing facility including manufacturing operations, inspection and utilities, as well as nonroutine activities such as process and product validation
Provides quality expertise and guidance to operational staff and within cross functional Amgen teams
Reviews and approves controlled documents, including but not limited to Standard Operating Procedures, Protocols and Reports
Ensures that operations align with applicable regulations and Amgen requirements relating to Good Manufacturing Practices, Good Documentation Practices, Safety, and Controls
Participates in Amgen internal/external audits and inspections
Directly interacts with regulatory agencies during on-site inspections
Contributes to and drives continuous improvement projects in cross-functional collaboration

What we offer

Retirement and Savings Plan with generous company contributions
group medical, dental and vision coverage
life and disability insurance
flexible spending accounts
discretionary annual bonus program
Stock-based long-term incentives
Award-winning time-off plans

Fulltime

New

Clinical Reviewer Specialist

Performs clinical reviews needed to resolve and process appeals by reviewing med...

Location

Philippines , Manila

Salary:

Not provided

NTT DATA

Expiration Date

Until further notice

Requirements

RN - Registered Nurse - State required Licensure and/or Compact State Licensure
Knowledge of utilization management process
Knowledge of NCQA, Medicaid regulations
Good communication (Demonstrate strong reading comprehension and writing skills)
Able to work independently, strong analytic skills
1-3 years of experience in processing appeals or utilization management

Job Responsibility

Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
Communicates with providers, facilities and other departments regarding appeal requests
Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeal requests
Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
Uses sound judgement, especially in non-routine appeals, to make decisions to keep the appeal process moving forward in accordance with contractual timeliness standards
Maintain files on individual appeals by gathering, analyzing and reporting verbal and written member and provider appeals
Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation
Prepare case recommendations for medical review as necessary

Fulltime

New

Inpatient Coding Team Lead

Baptist Medical Center Jacksonville is currently hiring for a Full-time Team Lea...

Location

United States , Jacksonville

Salary:

Not provided

Baptist Health (Florida)

Expiration Date

Until further notice

Requirements

High School Diploma
3-5 Years Experience working in an Acute Care setting
Knowledge base in Coding Clinic Guidelines
Knowledge base in Physiology
Knowledge base in Anatomy
Coding Experience
Knowledge of State and Federal Requirements
Leadership Experience
Registered Health Information Administrator - AHIMA
Registered Health Information Technician (RHIT) - AHIMA

Job Responsibility

Responsible for correctly identifying and assigning diagnosis and procedure codes using the ICD-10-CM/PCS Classification System to each patient's record for optimization in accordance with State and Federal requirements on Inpatient accounts
Be knowledgeable of CPT codes, edit resolution and assigning CPT-4 Codes on Observation accounts when applicable
Verifies and submits abstracted UB04 information across the billing system for claim submission
Must efficiently complete this activity for 100% of patient's discharged records daily to maintain the Coding A/R goals set forth
Works ACHA, DNFB and Post Bill error reports, such as A/B rebills, Claim Edits, and Denials when applicable
Advises and coordinates with Management, CDI and HIM on coding documentation
Provides support to Coders, CDI and other staff via mentorship, and possesses auditing and training skills
Requires critical thinking skills, effective communication skills, decisive judgement and the ability to work with minimal supervision
Must be focused and detailed oriented and have effective time management skills
Proficient in basic computer skills and able to utilize a computerized encoder and EHR

Fulltime

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Utilization Specialist

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