Utilization review nurse [h1.location_city]

REPORTS : Director of Utilization Review

DEPARTMENT : Clinical

LOCATION : George Rosenfield Center for Recovery - 13 Hell Gate Circle, Ward's Island, NY 10035

MAJOR FUNCTIONS :

Under the direction of the Director of Utilization Review, the Specialist will coordinate Medicaid Managed Care authorizations and re-authorizations for clients receiving behavioral healthcare services from Odyssey House's Part 820 residential programs. The Specialist will monitor claims and approvals, and coordinate internally and externally, to ensure uninterrupted service provision. This position is responsible for all verbal and written documentation as required by payers. Candidates must understand the various aspects of the managed care system including LOCATDR 3 criteria, behavioral health benefits, precertification, utilization review, peer reviews, discharge reviews, and appeals. Knowledge of substance use and mental health disorder treatments, including assessments, treatment planning, continuing care recommendations, DSM 5 and ICD 10 diagnostic codes, medications, and medicated assisted treatment is required.

SPECIFIC DUTIES & RESPONSIBILITIES :

• Complete utilization review-based documentation and all required updates.
• Complete utilization, discharge, and peer reviews.
• Initiate and resolve appeals.
• Ensure clinical documentation is up to date and complete.
• Utilizes the Concurrent Review / LOCATDR 3 to identify and advocate for appropriate level of care placement.
• Ensure that both effective utilization review management and client experience standards are maintained.
• Monitor concurrent and retro-review status.
• Help assess and implement systems and protocols to improve the utilization process.
• Meet regularly with multi-disciplinary team members concerning consumer and program issues; assists in development or modification of procedures for improvement of services.
• Stay abreast of new developments in the field of Quality Assurance / Improvement as related to substance use disorder and mental health treatment, recommend new policies and revise existing policies / procedures for compliance with all applicable laws and standards.
• Assist with training on relevant topics to management team, clinical staff, and other relevant GRCR staff.
• Prepare, file, and maintain department tracking systems related to authorizations and communications with clinical team as needed.
• Attend regularly scheduled staff meetings and case conferences.
• Attend all required in-service training seminars.
• Other relevant duties as required.

REQUIREMENTS :

In addition to competitive salaries, Odyssey House offers :

Odyssey House is an equal opportunity employer maintaining a non-discriminatory policy on hiring of its personnel. Odyssey House, and its operational divisions, will not discriminate against any employee or applicant because of race, creed, color, national origin, sex, disability, marital status, sexual orientation or citizen status in all employment decisions including but not limited to recruitment, hiring, upgrading, demotion, downgrading, transfer, training, rate of pay or other forms of compensation, layoff, termination and all other terms and conditions of employment.