About HBI: Careers
POSITION: Utilization Management (UM) Assistant
REPORTS TO: UM Supervisor
SUMMARY:
The UM Assistant receives and processes requests for authorization for services, benefits and eligibility and assists the UM Supervisor in completing the duties of the UM Department.
QUALIFICATIONS:
- College level/Bachelors Degree/Graduate from an accredited university
- Leadership experience with utilization management (mental health preferred)
- Knowledge and experience with managed care programs
- Knowledge and experience with Case Management fundamentals
- Working knowledge of community resources
RESPONSIBILITIES:
- Signs and complies with HBI’s Affirmative Statement Agreement
- Must have a keen understanding of the HBI UM Criteria
- Receives and inputs requests for authorizations for inpatient and outpatient services into the managed care program
- Receives clinical information and documentation in support of authorization requests for inpatient and outpatient services
- Completes HBI standard forms on Utilization Management
- Conducts Initial Screening of UM authorization requests
- Approves UM requests only if the HBI UM criteria is met (this position doesn’t have the ability to deny services unless he/she possesses the same clinical education of the requesting clinician)
- Coordinates referrals to Case Management Services for cases that they review
- Prepares and sends denial/appeal notification to the member and providers
- Consults with UM Supervisor, Clinical Director, Medical Director or UM Peer Clinical Reviewer on clinical questions or issues in the initial review process
- Daily administrative functions within HBI UM Department
- Maintain ongoing professional self development in UM or related clinical practice, with continuing education programs
- Attends HBI’s weekly clinical staffing meetings
- Reports critical incidents or high risk patients to the Clinical Director
- Participates in HBI’s annual performance appraisal
TASK SUMMARY
Core Tasks:
- Responsible for conducting ongoing, initial, availability, monitoring and processing of requests for authorization of mental health services
- Assists with the day to day phone calls at the Intake desk
- Verifies clinical UM information that applies to UM Criteria in order to make authorizations for services
- Issues approvals for UM requests that meet the UM Criteria for services
- Refers all UM requests that do not meet HBI UM Criteria to Clinical Director, Medical Director or UM Peer Clinical Reviewer (HBI does not issue non-certifications based on initial clinical reviews)
- After UM determinations are made, ensure that the authorization information is entered into the HBI UM system and issuance of the determination decisions to clinicians and/or patients if the patients have signed permission to receive correspondence from HBI
Secondary Tasks:
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Assists in the UM reporting to the Quality Improvement Committee
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Implements any QI Action Plans that effect the UM Department
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Additional duties as assigned by the UM Supervisor
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