Oasis Behavioral Health
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at Oasis Behavioral Health
The Utilization Review Director provides pertinent, timely clinical information to payer sources whenever it is requested, and ensures that discharge planning is underway by collaborating with the Utilization Review Coordinator. The Utilization Review Director is knowledgeable about issues that affect medical necessity for acute care, and communicates daily with the physicians, nurses, and therapists regarding the patient’s progress in treatment. Specialized interventions may be arranged and facilitated by the Utilization Review Director, when requested by the treating physician and treatment team. The Utilization Review Director works closely with the Utilization Review Director and Therapists to ensure that appropriate aftercare is planned, that appointments are made for patient follow-up, and that the patient’s insurance provider pre-authorizes these services.
The Utilization Director interacts with the admissions, billing, and medical records departments in order to ensure that proper authorizations have been acquired for patients’ care, and that records are sent to outpatient providers: when necessary, this position also executes the appeal process for account payments that have been denied due to lack of clinical information.
SUPERVISES THE UTILIZATION REVIEW DEPARTMENT
Ensures that coordination is made so that the department is present in each daily staffing, necessary concurrent reviews are completed daily, denial appeals are done timely to ensure payment for services rendered, interacts with physicians and staff to ensure appropriate documentation are present to support medical necessity and that communication with external reviewers are performed in a professional manner at all times.
Attends daily staffing to stay current with patients’ progress in treatment: collaborates with Physicians, Nurses, Therapists and Discharge Coordinator regarding medical necessity for acute stay, outpatient needs, and estimated length of stay. Reviews patient records and prioritizes clinical issues prior to contacting payer sources.
CONTACT WITH PAYER SOURCES
Ensures that each patient’s stay is authorized. Constantly interacts with the Admissions Director, Business Office Director and Program Directors; may be required to makes initial contact by phone with appropriate payer source representative (Reviewer) for newly admitted patients: reviews presenting clinical concerns, medications, plan of care for the patient, and faxes documentation as requested. Maintains on-going contact with Reviewer according to the schedule requested by the payer source.
Supervise Discharge Coordinators and occasionally may function as a discharge coordinator when necessary. Maintains regular contact with the therapist and Discharge Coordinator in a collaborative process to meet the patient’s needs for aftercare services. Ensures that the payer source authorizes the selected outpatient services and the service providers, prior to the patient’s discharge. In the absence of the Discharge Coordinator, the Utilization Review Director ensures coverage for this function and may assume the duties of arranging appropriate aftercare appointments for patients being discharged.)
The Utilization Review Director monitors the authorization for continued stay for each patient, and initiates the appeal process when payment for services is denied due to clinical concerns: this may require arranging a peer to peer review between psychiatrists in some cases: the Utilization Review Director may also be required to write a letter to appeal a decision by the payer source, and to ensure that the entire medical record is sent to the requesting party within the time frame allowed for the appeal.
Coordinates responsibility for the daily concurrent review to ensure that these are done appropriately and timely. Maintains a daily record of the concurrent review process, and informs the treatment team of the status of each patient’s authorization for continued stay. Synthesizes information from the daily staffing and the patient’s chart for telephonic delivery to the payer source, within the time frame requested by the payer source.