BEHAVIORAL HEALTH UR SPECIALST

The Behavioral Health Utilization Review Specialist collaborates with physicians and other staff members to provide accurate documentation necessary in conducting pre-admission and admissions reviews. These reviews will be completed concurrently to determine the appropriateness of hospital level of care. The Behavioral Health UR Specialist will determine the appropriateness for inpatient level of care based on documented severity of illness and intensity of services.

Essential Duties

• Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines and treatment guidelines.
• Collaborate with other clinical team members in reviewing actual and proposed psychiatric care and services against review criteria.
• Collaborates with Case Management Services in facilitating referrals to other facilities.
• Collaborates with physicians to influence appropriate utilization of resources and transitions from one level to another.
• Collaborates with revenue cycle in appeals of payer denials.
• Conducts admission and concurrent reviews on assigned patients.
• Demonstrates understanding of psychotropic medications.
• Demonstrates understanding of safety measures required for patient care (ie precautions, milieu rules, etc.)
• Educates members of the patient's healthcare team on the appropriate access to, and use of various levels of care.
• Encourage healthcare team members in collaborative problem solving activity regarding appropriate use of resources.
• Establish and maintain effective professional working relationships with patients, families, interdisciplinary team members, payers, and external case managers.
• Identify potentially unnecessary services and care delivery settings and recommend alternatives, if appropriate.
• Keeps current on all regulatory changes that affect delivery of reimbursement of acute care services.
• Maintain appropriate documentation on each patient in ACA notes.
• Participates in daily report and patient care staffings to maintain knowledge about intensity of services and the progression of care.
• Promote documentation that accurately reflects intensity of services, quality and safety indicators and patient's need to continuing stay.
• Recognizes and responds appropriately to risk factors.
• Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues.
• Works efficiently and completes work in established time frames.

Required Experience

• Behavioral Healthcare knowledge or experience is essential
• Must be able to demonstrate the ability to work independently and effectively as a healthcare team member and prioritize work.
• Must have interpersonal and communication skills.

Preferred Experience

• Utilization Management preferred

Preferred Education

• Bachelor's degree preferred

Employee Health Requirements

Exposure/Sensory Requirements:

Exposure to: 

• Chemicals: White out for correction of typing/writing corrections.
• Video Display Terminals: Average
• Blood and Body Fluids: Low risk
• TB or Airborne Pathogens: Low risk.

Sensory requirements (speech, vision, smell, hearing, touch):

• Speech: Required to communicate with physicians, hospital staff, and outside agencies.
• Vision: Needed to perform chart review data, computer screen work, reading data and information.
• Smell: NA
• Hearing: Needed for telephone communication.
• Touch: Needed to write, computer entry, individual pages of chart for review.

Activity/Lifting Requirements

Percentage of time during the normal workday the employee is required to:

• Sit: 70%
• Twist: 2%
• Stand: 10%
• Crawl: 0%
• Walk: 9%
• Kneel: 1%
• Lift: 4%
• Drive: 0%
• Squat: 1%
• Climb: 0%
• Bend: 2%
• Reach above shoulders: 1%

The weight required to be lifted each normal workday according to the continuum described below:

• Up to 10 lbs: Continuously
• Up to 20 lbs: Continuously
• Up to 35 lbs: Frequently
• Up to 50 lbs: Not Required
• Up to 75 lbs: Not Required
• Up to 100 lbs: Not Required
• Over 100 lbs: Not Required

Describe and explain the lifting and carrying requirements. (Example: the distance material is carried; how high material is lifted, etc.):

Lifting charts, notebook, notebook computers, office supplies. Carrying review books and notebook computers from department to nursing units. Charts carried from Medical Records to department. Handling files in file cabinet. Lifting manuals and reference information.

Maximum consecutive time (minutes) during the normal workday for each activity:

• Sit: 120
• Twist: 1
• Stand: 30
• Crawl: 0
• Walk: 10
• Kneel: 1
• Lift: 5
• Drive: 0
• Squat: 1
• Climb: 0
• Bend: 2
• Reach above shoulders: 1

Repetitive use of hands (Frequency indicated):

• Simple grasp up to 10 lbs. 
• Normal weight: 80%
• Pushing & pulling Normal weight: 4x/wk
• Fine Manipulation: Computer entry, writing.

Repetitive use of foot or feet in operating machine control: None

Environmental Factors & Special Hazards

• Environmental Factors (Time Spent):
• Inside hours: 8
• Outside hours : 0
• Temperature: Normal Range
• Lighting: Average
• Noise levels: Average
• Humidity: Normal Range
• Atmosphere: Odors, Dust

Special Hazards: NA

Protective Clothing Required: None