At SunCloud Health, we offer an integrated and holistic care model that is evidence-based and designed to maximize the value we can create for our patients and their families. Recognizing that eating disorders, addiction, mood disorders and trauma related disorders are associated with a tremendous amount of human suffering, disability, and premature mortality, we are committed to helping our patients achieve greater states of health.
Job Description:
• Be a part of weekly staffing to remind the team of upcoming reviews, current push back from insurance on specific cases, be made aware of upcoming discharges, potential step ups or step downs, and to gather general info from the team at that time.
• Communicate with the treatment team when missing clinical is needed for an upcoming review.
• Review the clinical in the medical record thoroughly and attentively to present during concurrent reviews, focusing on the medical necessity to prove needing further time in treatment.
• Communicate with the treatment team the result of each concurrent review and if there is any push back from insurance on potential future coverage.
• Obtain pre-authorizations for any step-up or step-down in level of care. (For current clients only)
• Meet weekly or as needed with the site director to go over documentation issues, questions, concerns, and acknowledge positive work.
• Timely document in the medical record all new authorizations and update the census spreadsheet when each new review is due.
• Keep track and monitor all last covered days (LCD) for each client on caseload, and promptly do concurrent reviews for continual coverage.
• Keep track of any unused days by client and request auth extensions in order to utilize all given days.
• Conduct retro reviews for any missed uncovered days.
• Initiate and schedule peer reviews and/or shaping reviews as the treatment team and CM deem necessary.
• Call or fax in discharge clinical to close out case.
• Initiate an expedited appeal if the option is available when a client is in imminent risk and in need of further coverage but has been denied after a peer review was conducted.
• Initiate a standard appeal after a client has discharged in order to get coverage for all uncovered days that resulted after a peer review
• Only report clinical to insurance what is true, accurate and reflected in the client's medical records
• Be able to effectively case conceptualize using the most current clinical at each concurrent review.
Requirements:
• LCSW, LPC, LCPC, or RN with previous work experience in Utilization Review in Behavioral Health for Levels of Care:
• Have a thorough understanding of what medical necessity qualifies for Inpatient, RTC, PHP and/or IOP levels of care.
Pay: $33.00 - $37.00 per hour
Work Location: Remote
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