Qualifications: Skills, Knowledge and Abilities

Needs basic understanding of and comfort level with medical terminology, residential treatment, clinical science/pathology and psychiatric disorders. Must know how to gather and analyze data. Must be articulate, assertive, and able to communicate effectively with families, payors, therapists and physicians both verbally and in writing. Must also demonstrate initiative, tact and good judgement. Must be able to acquire clear understanding of treatment priorities and ability to make sound decisions balancing resident and family needs with available resources. Must have basic computer skills.

Education: Bachelor’s Degree in related field.

Experience: Must have a Bachelor’s degree in appropriate Human Services field (Masters preferred). Two (2) years previous experience with psychiatric standards

Physical

Requirements: Must be able to mentally handle stressful and quick changing situations. Must have normal auditory processing. Must have clear verbal speech with no impediments. 50% of time, incumbent is seated and talking on the phone or using a computer. Must have a valid Virginia driver’s license.

Exposure

• Coordinates the development, implementation and monitoring of facility-wide UM program consistent with third party payors, managed care, Federal, State, and CARF standards.
• Develops systems to review and respond to concerns expressed by customers. Together with the appropriate Department Head, he/she works to resolve issued to the satisfaction of the customer and facility. The Director of UM recommends changes in order to protect the integrity of our customer commitment pledge.
• Review of clinical patient data with third party reviewers to substantiate the need for continued hospital level of care of ongoing participation in treatment programs.
• Communicate and coordinate third party reviewer’s level of care decisions and expectations to appropriate clinical and administrative staff.
• Facilitate physician reviews with medical staff and third party reviewers.
• Attend daily multidisciplinary treatment team meetings
• Participate in presentations of summaries of case management issues and proposed plans for action.
• Complete Utilization Review sheets, enter data into computer, and analyze results.
• Prepare Utilization Review Reports as necessary.
• Maintains records associated with UM activities and Medical Records.
• Coordinates and makes Retrospective Appeals to third party payers.
• Complies, analyzes, and disseminates information and statistics relative to UM, including monthly facility utilization data, medical record chart reviews, service utilization, and special surveys.
• Completes monthly, quarterly, and annual UM reports in compliance with facility policies and procedures.
• Participates in staff education programs and in-service training pertaining to the facilities UM process and monitoring activities.
• Regularly reviews and revised facility policies and procedures pertaining to UM.
• Influences others by demonstrating leadership skills thus establishing a climate for optimal personal and professional growth.
• Approaches situations/events with a process improvement perspective.
• Maintains collaborative relationships with other healthcare professionals and allied workers using good communication skills, via written and verbal formats.
• Utilizes supervisory feedback to improve performance.
• Meets weekly with Administrator on appropriate issues.