Utilization Review Tech

Job Summary:

MedStar Health is looking for a Utilization Review Technician to join our team at MedStar Harbor Hospital.

The Utilization Review Technician will collaborate with and assist the multidisciplinary team to meet individualized patient outcomes. Performs admission and subsequent concurrent reviews based on approved screening criteria, knowledge of insurance coverage, and communication with the third-party payers.

Join one of the largest healthcare systems in the Baltimore-Washington metro region, also recognized as one of the "Healthiest Maryland Businesses". Apply today and learn how MedStar Health can be your next great career move!

Primary Duties:

• Actively participates in ongoing professional enrichment and educational opportunities. Collaborates with and assists the multidisciplinary team to meet the patients' continuing health needs in a high quality, cost-effective manner. Participates in planning rounds as needed to address and communicate issues related to acuity level of patient, LOS, insurance, and discharge needs. Integrates and evaluates discharge planning needs with multidisciplinary team to ensure a positive patient outcome.

• Collects quality improvement data in accordance with approved indicators. Recognizes potential problems and makes referrals to quality improvement, risk management, safety, infection control, and other departments as appropriate. Confers and collaborates routinely with the physician advisor, division chiefs, and attending physicians to resolve problems regarding acuity and level of care. Collaborates with outpatient providers to provide continuum of care for community resources.

• Evaluates concurrent and retrospective denials for appeal opportunities. Generates appeal letters based on knowledge of clinical severity and intensity. Identifies insurance information, obtains authorization, communicates with financial counseling, and assigns appropriate length of stay for admission. Identifies network providers for discharge planning needs and facilitates appointments. Collects data in collaboration with Case Management to support appeal process.

• Implements strategies to avoid denials including potential denial notification to attending physician. Issues letters of noncoverage for Medicare or third-party payers according to policies and procedures. Communicates utilization plans to multidisciplinary team. Ongoing collaboration routinely with Social Work and physicians for continued update and revision of discharge plan to provide appropriate utilization of resources and to insure optimal patient outcomes.

• Performs admission and subsequent concurrent reviews to determine the necessity for acute care by application of accepted criteria based on age specific needs. Interacts with and assists third party payer reviews to facilitate appropriate care and ensure payment for services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources. Collects data in collaboration with third party payers to insure appropriate use of resources. Serves as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services, staff meetings, orientation, and formal educational offerings.

Qualifications:

• Associate's degree in Psychiatry or related field.

• 1-2 years' experience in utilization/discharge planning.

• 5-7 years' clinical experience in acute care setting preferred.