Registered Nurse (RN) - Utilization Review Behavioral Care, PRN, Day

Inspire health. Serve with compassion. Be the difference.

Job Summary
Performs systematic review of patient charts in order to assess medial necessity and relay information to managed care, review and insurance companies (third party payers). Works collaboratively with the physician and treatment team to secures authorization of payment for patients' services. Documents and provides communication to treatment team (including physician), Business Office and Patient Accounts. Serves as liaison in coordination of pre-certification and concurrent review requirements. Coordinates the preparation of appeal efforts in cases of third party denials.

Essential Functions

• All team members are expected to be knowledgeable and compliant with Prisma Health's values: Inspire health. Serve with compassion. Be the difference.
• Performs review of patient medical record and documents patient symptoms, progress, mental status, treatment plan, changes and pertinent information needed for communication with third party payers.
• Utilizes critical thinking skills to analyze patient progress and records to determine legitimacy of admission, treatment, and length of stay to comply with governmental and insurance company reimbursement policies. Applies knowledge of payer requirements, contractual obligations with payers, and federal and state regulations in review of cases.
• Documents in hard copy as well as in Patient Accounts system the results of the review and financial status of the authorization. Communicates verbally and in writing as needed with various members of treatment team, Business Office and Patient Accounts regarding third party information. Reminds treatment staff of limitations in coverage, makes necessary requests for more or additional information.
• Establishes positive working relationships with treatment team staff. Develops and demonstrates familiarity with physicians' treatment patterns, communicating these to insurance reviewers. Attends treatment team meetings regularly.
• Communicates with third party payers either via telephonic review or written review. Provides appropriate information and seeks information as requested. Advocates for patient care and treatment plan. Establishes positive and productive relationships with reviewers/case managers.
• Validates the length of stay/treatment and medical necessity through a concurrent review of patient chart and via verbal communication with treatment team, ensuring that the documentation of the severity of illness and intensity of service is clearly indicated according to established criteria.
• Demonstrates familiarity with medical necessity criteria, DSM-IV and ASAM guidelines. Communicates these effectively to treatment staff and insurance reviewers.
• Demonstrates knowledge of psychiatric treatment modalities, psychotropic medications, and treatment trends, modalities, "best practices" in order to monitor and provide review information as appropriate. Attends continuing education, in services and related seminars for professional development.
• Collaborates with Medical Information, Clinical Assessment & Referral Center, and Business Office Staff in order to accomplish the goal of patient advocacy. Applies knowledge to ensure efficient workflow.
• Coordinates and prepares appeals for denied authorizations.
• Assists Business Office with the preparation of hospital-issued notices of non-coverage, where appropriate
• Abstracts data from records, tracks and documents statistical information for the department. Submits reports as requested.
• Performs other duties as assigned.

Supervisory/Management Responsibilities

• This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Requirements

• Education - Associate degree in Nursing. Bachelor's degree in Nursing preferred.
• Experience - Five (5) years- inpatient psychiatric experience. Psychiatric case management or utilization review experience preferred. Managed care, insurance reimbursement, utilization review experience preferred

In Lieu Of

• NA

Required Certifications, Registrations, Licenses

• RN - REGISTERED NURSE - NLRN

Knowledge, Skills and Abilities

• NA

Work Shift
Day (United States of America)

Location
Greenville Memorial Med Campus

Facility
1007 Marshall I Pickens Hospital

Department
10077500 Medical Management

Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.