1) Directs the supervision of UR Technician and assists with pre-certification and concurrent reviews.
2) Acts as a liaison between managed care organizations and facility clinical and medical staff.
3) Conducts clinical/medical reviews in accordance with certification requirement of each client’s insurance plan.
4) Makes required phone and/or written contacts with managed care organizations to obtain necessary certifications and continuing care referrals.
5) Keeps accurate records of all contacts with external organizations/ persons (i.e. managed care, insurance companies, referrals, family members) who have legitimate interest in the client’s care.
6) Conducts negotiation of rates with managed care companies under the direct input from the Clinical Director and reports successful negotiations to the Financial Office for appropriate billing of the claim.
7) Facilitates peer review calls between facility doctors and managed doctors including assisting White Deer Run doctors in the acquisition of pertinent clinical information.
8) Informs clinical/medical staff of any specific concerns that would extend or restrict a client’s length of stay by the various managed care standards.
9) Provides information to managed care providers about alternative levels of care within the White Deer Run System and accurately promotes the utilization of these services.
10) Acts in coordination with the Clinical Director to constantly improve the quality of services provided to organizations that have provider contracts with White Deer Run.
11) Assists, whenever necessary, the Admission Department in pre-certification of care for clients planning to enter treatment.
12) Upon denial of certification, review chart with Clinical Coordinator, Director of Clinical Services and/or Administration and the Finance Office as on how to proceed with the appeals process.
13) Provides ongoing support and training for clinical/medical staff on documentation strategies, continued stay criteria and meeting specified charting requirements for various payers.
14) Monthly audit of clinical/medical charts with regard to timeliness of documentation, quality and appropriate level of care.
15) Assists Clinical Coordinators in developing a plan to strengthen documentation skills of clinical staff and to improve outcomes with the managed care concurrent review process.
16) Advises Clinical Coordinators/staff of continued stay criteria for various payers.
17) Conducts formal and informal in-service trainings for all clinical staff on the documentation of “medical necessity”, which includes a working knowledge of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria.
18) Acts as an active member of the Clinical Care Committee.
19) Attends multidisciplinary staff meetings each week.
20) Initiates Emergency Team Meetings.
21) Develops statistical and narrative reports on the utilization and quality of services provided at White Deer Run.
22) Gathers and reports on all discharge statistics as required by the Corporate Office, Executive Director, Administrator and Director of Clinical Services.
23) Monitors and reports on utilization of the Family Program.
24) Gathers and reports on non-routine discharges, including identifying trends that contribute to the AMA/AD rate.
25) Reports on all non-certified days, which includes the identified causes of non-certification and information in the appeal process.
26) Writes a daily report detailing all review calls of the previous business day to be reviewed in the Morning Report.