Utilization Management Reviewer

Responsibilities

• Reviews medical records and attends treatment team meetings to review utilization of resources and the level of care provided.
• Ensures utilization and level of care are appropriate based on the diagnosis, needs, age and culture of the individual.
• Carries out appropriate telephone and written communication with insurers and third party payers regarding referrals, admissions, medication changes, discharges and changes in level of care.
• Collaborates on-site review of medical records with reviewers from third party payers.
• Documents, updates, and manages patient and provider information using internal electronic records system.
• Coordinates psychiatric consultations between internal and external providers.
• Investigates complaints, grievances, and medication variances. Reports findings to Utilization Management Manager and completes necessary follow up.
• Responds to changing needs of the departments (i.e., program design, forms development, reporting mechanisms, etc).
• Establishes and maintains effective working relationships with staff members to assure professional interactions.

Qualifications

• In order to be considered candidates must have one of the following:
• Registered Nurse: Associate Degree in Nursing required. One year experience in psychiatric nursing required. Valid Florida RN License required.
• Licensed Practical Nurse: Graduation from an accredited school of Practical Nursing required. Two years experience in psychiatric nursing required. Valid Florida LPN License required.
• Master’s degree in Psychology or Human Services related field required. Three years experience in the mental health field required. UM experience preferred.

Position Details

• This is a full time position, Monday through Friday, 7:00am to 3:30pm