Hours/Shift: Full Time, Days
The position can be a hybrid role with days on site and others remote once the onboarding is complete and the person has demonstrated the ability to work independently.
Primary responsibilities include:
- Complete and manage all authorizations for designated unit including: initial, continued stay, change in level of care, discharge, retrospective, and mange denials through complete appeal process
- Support attending MDs and NPs in completing peer to peer reviews and may complete peer to peer reviews as licensure allows
- Participate in Utilization Review Committee functions, team meetings, and treatment ream conferences with third party payors.
- Engage in clinical rounds as an active treatment team member providing guidance on level of care recommendations, and providing feedback on what will be needed for authorization of clinically indicated services and to decrease peer to peers
- Supporting treatment team members by explaining services covered by the members benefits and advocating with third party payor for services and coverage
- Coordinate with Leadership and other departments as needed to ensure highest quality of advocacy and access to care for our patients
- Monitor internal utilization of services using data from multiple sources with the goal to optimize care
- Maintain up to date knowledge of utilization review trends, Medicaid and Medicare benefits, plan structure, and medical necessity criteria
- Master’s degree from an accredited program in Human Services, BSN or equivalent
- 2+ years’ experience providing direct clinical care in a mental health setting, preferably in an eating disorder /residential psychiatric setting. Utilization management experience strongly preferred.
- LICSW, LMHC, Ph.D., RN, or equivalent active Independent Professional Licensure in MA
- Knowledge of the Utilization review process which is to insure that cases are formulated in a comprehensive manner, that realistic goals are set, that patient severity of illness indicators are objectively presented, and that treatment is provided at the most appropriate level of care. An understanding of severity of illness and intensity of service criteria for various levels of care. Familiarity with the utilization review requirements of Joint Commission, Medicare, and other third and fourth part payors.
- Reports to Director of Utilization Management
- Competitive compensation
- Comprehensive Benefits Package (Medical/Dental/Vision Coverage)
- Flexible Spending Accounts for medical and dependent coverage
- Tuition reimbursement
- Paid time off
- Unparalleled mentoring in support
- Many more!
About Walden Behavioral Care. Walden Behavioral Care is a rapidly-growing, national mental healthcare system specializing in the treatment of eating disorders and mental health conditions. We are one of the only organizations in the country to welcome individuals of all ages and all genders at all levels of care. Since 2003, we have helped more than 20,000 individuals progress in their path to healing. With 15 locations and more than 450 dedicated care professionals across Connecticut, Massachusetts and in Georgia, we are committed to changing lives, one person at a time. Using evidence-based treatment, proven to support long-term recovery, we are passionate about providing all individuals with the specialized care they need and deserve.