Utilization Management Reviewer - Full Time at Penn Medicine Princeton Health

Responsibilities:

• Perform admission review for assigned patients to determine the medical necessity and appropriateness of admission based on departmental policy and procedure. Maintain system for monitoring admissions to assure the review of extended stay and communication of such information to insurance providers/managed care companies in a timely fashion. Maintains a schedule of additional review dates for patients requiring concurrent review. This information is to be maintained in the SQL Database as per department policies and procedures. Conducts Utilization Management reviews for assigned patients, regardless of their insurance, to determine need for treatment and appropriateness of care. Discusses concerns regarding these issues with the attending physician, and if necessary, the treatment team and proactively works to resolve UM issues.

Credentials:

• LCSW or L-LAC or LPC or LSW or RN-NJ (Required)

Education or Equivalent Experience:

• Masters level degree in healthcare field, OR significant combination of credentials and experience for the job (i.e., RN, LPN, BSW, etc.) Required.
  
• Experience maintaining clinical competence in specific area of expertise (required).
  
• Experience in psychiatric care and / or addictions treatment, with a minimum of five (5) years’ clinical experience (Required).
  

Specialized Skills & Knowledge Requirements:

Ability to read and comprehend basic instructions, correspondence, memos and similar business materials. Ability to write business-related
correspondence, including appeal letters. Ability to interact with healthcare professionals in all disciplines in order to assemble and communicate
a clear, concise understanding of the patient’s healthcare needs. Adequate typing skills are essential, typing a minimum of 35 words per minute.

Organizational, quantitative and analytical skill relevant to creating and/or reading reports and identifying trends. Ability to multi-task, including
applying problem-solving skills to situations involving multiple variables that arise in the inpatient setting.

Familiarity with health insurance, managed care organizations, third party payors, and level of care criteria.

Possession of strong clinical skills and knowledge of behavioral health resource management and ability to prepare clinical reviews to managed
care companies and insure appropriate and necessary utilization of Princeton House internal resources.

Ability to develop good working relationships with managed care organizations, and to provide excellent customer service. Must be able to be
proactive, demonstrate strong negotiation skills, and patient/institution advocacy skills.

Ability to develop good working relationships with managed care organizations, and provide excellent customer service. Must be able to be
proactive, demonstrate strong negotiation skills, and patient/institution advocacy skills.
Professional composure is required in all interactions with managed care organizations under all circumstances.

Adequate typing skills are necessary, typing minimally 35 words per minute.

A strong attention to detail is required, so as to minimize any misunderstandings regarding services, which are certified, and strong
communication skills to impart this information to the treatment team, Administration, and Billing Services.

Ability to multitask and work in a fast paced environment with constant interruptions.