UM Coordinator - Utilization Review - F/T Days - Hackensack Meridian Health

Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change. 

The Utilization Management Coordinator utilizes clinical knowledge and understanding of behavioral health resource management to review and coordinate the care for a designated patient caseload. Collaborates with the attending LIP, Clinical Case Manager, nurse, and other members of the treatment team, ACCESS center staff and PFS department to ensure appropriate utilization of resources and benefits on a case by case basis. Applies case management and utilization review principles in monitoring the delivery of care and promoting optimal communication among treatment team members, intra and interdepartmentally and with all payers. Interacts with the treatment team and third party payers to obtain certification for medically necessary acute inpatient hospitalization and to facilitate transfer to the appropriate alternative level of care setting for continued treatment. Employs the utilization management process to assist in setting priorities, planning, organizing, and implementing a plan of care directed toward stabilization and transition to the next appropriate level of care.

Education, Knowledge, Skills and Abilities Required:

• RN, BSN, or Bachelors degree in a clinical field with a health care focus
• Minimum five years of clinical experience in a behavioral health care setting.
• Excellent written and verbal communication skills.
• Proficient computer skills that may include but are not limited to Microsoft Office and/or Google Suite platforms.

Education, Knowledge, Skills and Abilities Preferred:

• Master's Degree

Licenses and Certifications Preferred:

• NJ State Professional Registered Nurse License or NJ Licensed Social Worker

• Perform admission reviews to assure that the level of care criteria are met.
• In collaboration with the Access Center and Unit staff, assure that certification is completed at the earliest possible entry into the system, and recertification occurs timely.
• Perform concurrent reviews with third party payers and communicate potential or identified concerns to the treatment team, Director of Utilization Management, and the Medical Director.
• Review charts at identified review points and attend treatment planning conferences or team meetings, collecting data pertaining to clinical status and justifying the medical necessity for continued treatment in inpatient level of care. Referral of cases with questionable medical necessity to Physician Advisor for determination.
• Review clinical and diagnostic interventions for appropriateness and timeliness to achieve optimal clinical and financial patient outcomes.
• Participate in interdisciplinary team meetings as it relates to the following: insuring appropriate length of stay, reviewing treatment interventions, developing and implementing discharge plans.
• Collaborate with Patient Financial Services, Access Center and the clinical treatment team to insure optimal reimbursement for services provided.
• Review concurrent denials from third party payers with the interdisciplinary treatment team and orchestrate the appeal process where indicated.
• Anticipate patients' readiness for discharge, and collaborate with primary therapists and discharge planners regarding transition to alternative levels of care.
• Perform concurrent utilization review applying identified criteria at prescribed review points, and retrospective focus reviews in concordance with department objectives.
• Perform all administrative tasks related to caseload such as Meditech documentation, continuity of care referral paperwork, team, committee, or special project reports, etc.
• Maintain competencies and professionalism by participating in educational opportunities with focus on case management, psychiatric and/or additional treatment issues/trends.
• Participate in the development and refinement of the Case Management Program.
• Participate in department and hospital committees.
• Other duties and/or projects as assigned.
• Adheres to HMH Organizational competencies and standards of behavior.