Utilization Review/Business Office Manager | Fair Oaks Recovery Center | Sacramento, California
About the Job:
The Utilization Management Manager is responsible for the overall management of the UM department by leading and facilitating review of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria. Directs and manages the day-to-day operations and supervision of staff to obtain coverage for clients, monitors the progress of all UR cases and insurance appeals, problem solves when necessary and mitigates all issues with utilization. Monitors utilization of services and optimizes reimbursement for the facility while maximizing use of the client’s provider benefits for their needs.
Leads and provides operational directives for all Business Office activities related to the claim’s management and collections of the facility receivables and ensures timely, efficient cash collections to support the overall financial goals of the facility. Plans, develops, organizes, implements, evaluates and supervises business office activities including the financial counselling, billing, and collections functions for all service lines.
Roles and Responsibilities:
- Assigns all clients to Utilization Review staff and supervises staff to ensure staff are completing insurance verifications on time and compliant with regulatory standards and requirements.
- Ensures staff are competent to review medical records of clients for appropriateness of level of care at admission and at intervals determined by documentation in medical record and to communicate client insurance status and needs with all disciplines.
- Leads a team of highly engaged members thru hiring, orienting, performance assessment and management, motivating, training, scheduling, and coaching to meet department goals and ensure effective and efficient department operation.
- Works closely with Admissions Department to ensure client information is accurate and pre-certification is complete. Reviews application for client admission and approves admission or refers case to utilization review committee for review and course of action when case fails to meet admission standards.
- Manages any discrepancies regarding stated benefit information and insurance verification, need for updated benefits or follow-up on a problem with a pre-certification from admissions.
- Appeals all denials ensuring accuracy of information and effective coordination of correspondence.
- Analyzes client records to determine appropriateness of admission, treatment, and length of stay to comply with government and insurance company reimbursement policies. Ensures charting deficiencies are minimized and corrected timely by responsible staff. Identifies and forwards charts for review based on outlying data to the Medical Director.
- Analyzes insurance, governmental and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of clients.
- Compares client’s medical records to established criteria and confers with medical, clinical, nursing, and other professional staff to determine appropriateness of treatment and length of stay. Communicates and coordinates information with business office to recognize and resolve potential payment issues.
- Conducts and oversees concurrent and retrospective reviews for all clients. Assists review committee in planning and holding mandated quality assurance reviews.
- Acts as a liaison between Medicaid reviewers and the staff completing required paperwork to facilitate the Utilization Review process.
- Explains benefits and establishes contractual agreements and payment plans with clients and their family members.
- Establishes and maintains controls for all cash collected and posted in client accounting system. Monitors bank activity and collects revenue/completes deposits in a timely manner.
- Leads a team of highly engaged members thru hiring, orienting, performance assessment and management, motivating, training, scheduling, and coaching to meet department goals and ensure effective and efficient department operation.
- Prepares and maintains client statements and follows up as needed. Maintains client financial records.
- Monitors outstanding claims with managed care organizations (MCO) and other agents on a consistent basis. Manages actions relating to delinquent accounts and collection agencies.
- Monitors and reports on key metrics such as cash collections, days outstanding, daily cash, unbilled, denials, daily census, etc.
- Maintains effective communication with third party insurance carriers to resolve issues that impede cash flow and detract from client satisfaction.
- Selects and monitors outside collection vendors engaged in the collection of facility receivables. Reviews and balances agency reports to system reports and approves agency invoices.
- Reviews all statistical reports to monitor trends and determine operational deficiencies and implements corrective action plans as necessary.
- Works closely with Utilization Review and Admissions staff to ensure proper authorization of client insurance coverage.
- Communicates effectively with the leadership team to ensure that all third-party compliance guidelines are met. Communicates with Centralized Business Office (CBO) and provide documentation and account information as needed.
- Assists in various audits and preparation of any special reports that may be necessary.
- Assists in month-end close.
Qualifications
- Graduation from an accredited school of nursing OR a Bachelor's degree in social work, behavioral or mental health, or other related health field required. Master's Degree in same field preferred.
- Four or more year's clinical experience with the population of the facility and previous experience in utilization management required.
- Two or more years’ experience in medical/psychiatric utilization management required.
- Comprehensive understanding of the admission, concurrent, continued stay, and retrospective reviews using the established facility criteria.
- Two or more years’ of Business Office experience, preferably in behavioral health required.
- Experience in a billing practice including exposure to verification, certification, authorization, managed care, revenue capture and relationship building with payers required.
- Strong revenue cycle technical skills required.
- Ability to communicate professionally and effectively with multidisciplinary team members, managed care organizations and business office, providing needed information in a logical, concise manner using technical language that accurately describes client’s condition.
- Current licensure as an LPN or RN or current clinical professional license or certification, as required, within the state where the facility provides services.
- CPR and de-escalation certification required (training available upon hire and offered by facility).
- Graduation from an accredited school of nursing OR a Bachelor's degree in social work, behavioral or mental health, or other related health field required. Master's Degree in same field preferred.
- Four or more year's clinical experience with the population of the facility and previous experience in utilization management required.
- Two or more years’ experience in medical/psychiatric utilization management required.
- Comprehensive understanding of the admission, concurrent, continued stay, and retrospective reviews using the established facility criteria.
- Ability to communicate professionally and effectively with multidisciplinary team members, managed care organizations and business office, providing needed information in a logical, concise manner using technical language that accurately describes client’s condition.
- Current licensure as an LPN or RN or current clinical professional license or certification, as required, within the state where the facility provides services.
- CPR and de-escalation certification required (training available upon hire and offered by facility).
Why Fair Oaks Recovery Center?Fair Oaks Recovery Center offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications. Qualified candidates should apply by submitting a resume. Fair Oaks Recovery Center is an EOE.
Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.