LVN- UR COORD PRN

POSITION SUMMARY

The UR Coordinator is responsible in facilitating a continuum of service while promoting outcome and optimal reimbursement through coordination of patient care, daily clinical reviews, quality documentation, appeals, and reporting

QUALIFICATIONS

Education: Bachelor's degree from an accredited college or university in social work, mental health or a Nursing degree is preferred.

Experience: A minimum of 3-5 years of experience working in an acute inpatient psychiatric setting as a treatment team member and/or utilization management, or a minimum of three years utilization management experience within a payer organization.

This is a temporary position.

Licensure: CA L.V.N required

Additional Requirements: Knowledgeable in behavioral health managed care and clinical assessment skills to align patient acuity with level of care practice guidelines - Diagnostic and Statistical Manual of Mental Disorders (DSM-V).

Solid understanding of acute inpatient psychiatric hospital operations, including both mental health and substance abuse treatment.

Effective oral and written communication skills to support patient advocacy/negotiating skills to ensure quality reviews with payers

STANDARDS OF PERFORMANCE

THE ESSENTIAL JOB FUNCTIONS ARE CATEGORIZED UNDER THE JCAHO STANDARDS OF PERFORMANCE.

1. Knowledgeable in behavioral health managed care and clinical assessment skills to align patient acuity with level of care practice guidelines - Diagnostic and Statistical Manual of Mental Disorders (DSM-V).
2. Performs timely, daily clinical reviews with all payer types (Managed Medicare, Managed Medicaid and commercial) to secure authorization for continued treatment (i.e. by fax, telephone or on-line) based on payer's criteria.
3. Functions as a key member of the multidisciplinary treatment team to educate and guide on level of care requirements and payer expectations for patient acuity and appropriate utilization.
4. Completes quality and timely appeal/denial letters. Participates in post claim recovery review and ongoing audit activity, supporting compliance with CMS and other regulators.
5. Works collectively with hospital operations (social services, business office, Intake, Nursing) to ensure timely documentation is aligned with patient conditions.
6. Contributes to monthly utilization data trends using hospital data tools to report for the overall operation.
7. Facilitates physician reviews with payers as required.
8. Work with the treatment team regarding the Continuum of Care Plan and collaborate with the team when changes are needed.

1. Ensure that the patient attends the appropriate level of care or program as indicated on the treatment plan or as needed when there are changes in the patient's status.
2. Interface with the staff of the appropriate level of care to facilitate a smooth transition at the time of transfer.
3. Assure proper tracking of all reviews.
4. Communicate and enforce the documentation requirements with all levels of staff to meet accreditation and certification body regulations.
5. Initiate the denial process and maintain current information at all times in the UR file, and initiate appeals through telephone or written communication.
6. Promote an effective use of resources for patients, customers and the facility with sensitivity to the cost of health care.
7. Ensure that patient rights are upheld.
8. Advocate for the lowest level of care consistent with patient needs.
9. Function as a resource for patient/families/significant others.

Utilization Review

1. Assist potential patients in gaining access to federal and state support systems.
2. Consult with the business office and/or admission staff as needed to clarify data and ensure the insurance precertification process is complete.
3. Provide clinical precertification information to patients, managed care companies, insurance companies and other third party reviewers to establish the length of stay or number of certified days.
4. Coordinate with the insurance company doctor in appeals process and denials process.

Specific Standards for the Care of Child Patients Ages 5 through 11

1. Maintain knowledge of the Child Program rules, protocols and handbooks guidelines.

Specific Standards for the Care of Adolescent Patients Ages 12 through 18

1. Maintain knowledge of the Adolescent Program rules, protocols and handbooks guidelines.

Specific Standards for the Care of Adult Patients Ages 19 through 64

1. Gather information from the patient, family and interdisciplinary team and use judgements based on knowledge of adult behaviors in treatment planning and interventions.

1. Maintain current knowledge of the Adult Program rules, protocols and handbook guidelines.

Specific Standards for the Care of Geriatric Patients Ages 65 and older

1. Maintain a complete knowledge of treatments, medications and side effects of such in the geriatric age group.

Specific Standards for the Care of Chemically Dependent Patients

1. Collaborate with other chemical dependency staff professionals in planning for discharge and follow-up care.
2. Maintain an awareness of how personal issues relating the co-dependency can impact work performance/relationships.

Additional Responsibilities

1. Adhere to facility, department, corporate, personnel and standard policies and procedures.
2. Attend all mandatory facility in-services and staff development activities as scheduled.
3. Adhere to facility standards concerning conduct, dress, attendance and punctuality.
4. Support facility-wide quality/performance improvement goals and objectives.
5. Maintain confidentiality of facility employees and patient information.
6. Other duties as directed or assigned.

Note: The essential job functions of this position are not limited to the duties listed above.

KNOWLEDGE, SKILLS, AND ABILITIES

THIS SECTION DESCRIBES WHAT KNOWLEDGE, SKILLS AND ABILITIES AN EMPLOYEE IN THIS POSITION SHOULD CURRENTLY POSSESS. THIS LIST MAY NOT BE COMPLETE FOR ALL KNOWLEDGE, SKILLS AND ABILITIES REQUIRED FOR THIS POSITION.

1. Knowledge of case management techniques.
2. Knowledge of patient assessment, family motivating treatment planning techniques.
3. Knowledge of external review organizations (i.e. managed care, Medicare, Medicaid).

1. Knowledge of patients' rights, advanced directives, adult and child abuse laws, and emergency detention.
2. Knowledge of complex patient care planning.
3. Knowledge and utilization of crisis intervention techniques.
4. Knowledge of payor resources and financial planning.
5. Excellent leadership and negotiation skills.
6. Excellent customer relations skills.
7. Excellent organizational and interpersonal communication skills.
8. Skill in interacting with multiple individuals with diversified roles and perspectives.
9. Skill in organizing and prioritizing workloads to meet deadlines.
10. Skill in telephone etiquette and paging procedures.
11. Effective oral and written communication skills.
12. Ability to communicate effectively both verbally and in writing.
13. Ability to handle conflicting situations.
14. Ability to focus on details in a busy environment.
15. Ability to operate in an unstructured environment, orchestrate a myriad of activities and to manage multiple priorities within complex systems.
16. Ability to tolerate ambiguity, uncertainty, and change.
17. Ability to work at a rapid pace.
18. Ability to communicate effectively with patients and co-workers.
19. Ability to adhere to safety policies and procedures.
20. Ability to use good judgement and to maintain confidentiality of information.
21. Ability to work as a team player.
22. Ability to demonstrate tact, resourcefulness, patience and dedication.
23. Ability to accept direction and adhere to policies and procedures.
24. Ability to recognize the importance of adapting to the various patient age groups (adolescent, adult and geriatric).
25. Ability to work in a fast-paced environment.
26. Ability to meet corporate deadlines.
27. Ability to react calmly and effectively in emergency situations.

PHYSICAL, MENTAL, AND SPECIAL DEMANDS

THIS SECTION DESCRIBES HOW AN EMPLOYEE IN THIS POSITION CURRENTLY PERFORMS THE FUNCTIONS OF THIS POSITION. MODIFICATIONS TO THE MANNER IN WHICH THIS JOB MAY BE PERFORMED WILL BE REVIEWED ON A CASE BY CASE BASIS.

1. Ability to stand, or walk up to six hours, sit for up to two hours.
2. Ability to spend 20% of the workday outdoors in temperatures varying from 30 -100^oF and 80% of the workday indoors in temperatures varying from 60 -85^oF.
3. Ability to occasionally push/pull wheeled carts from 200 lbs. (i.e. crash carts, patient on stretchers or in wheelchairs).
4. Ability to frequently lift and carry up to 10 pounds; and occasionally lift and carry up to 100 lbs.
5. Ability to see well enough to read written materials.
6. Ability to discern a variety of odors.
7. Ability to handle hazardous/infectious waste on an occasional basis.

1. Ability to work in an environment where the noise level is frequently high; where chemicals are frequently used in cleaning; where mechanical and electrical hazards may occasionally be present; and where dust, mist and stream are frequently generated in housekeeping tasks.
2. Ability to respond to exposure to blood and bodily fluids.

MACHINES, TOOLS, EQUIPMENT, AND OTHER WORK AIDES:

THIS SECTION DESCRIBES THOSE MACHINES, TOOLS, EQUIPMENT, AND OTHER WORK AIDES AN EMPLOYEE IN THIS POSITION MUST BE ABLE TO USE.

1. Computer and various software packages.
2. Telephone and paging system.
3. Fax machine.
4. Calculator/10-Key.
5. Copy machine.
6. Medical Records
7. Policies, procedures, plans and program manuals.