Job: Utilization Reviewer

This posting has expired and is no longer available.

Job Description

Want to make a difference? Join our team of dedicated professionals providing support and treatment to at-risk children and youth facing mental health, child welfare and criminal justice issues. Through our Crisis Stabilization Unit (CSU), Staff Secure Residential Unit (SSR), hospital diversion program (New Vistas) and Jefferson Hills Academy, we use some of the most current practices, interventions and protocols to address the complex needs of vulnerable youth and their families.

 Utilization Reviewer Position Purpose:

A Utilization Reviewer coordinates and communicates with Behavioral Health Organizations and insurance companies to ensure the effective and efficient use of New Vistas and Crisis Stabilization Unit services. This is performed in accordance with the medical necessity guidelines set forth by each BHO and insurance company. The Utilization Reviewer works in collaboration with the treatment team and under the direct supervision of the CFO. Responsibilities include:

  • Analyzes patient records to determine medical necessity related to length of stay to comply with insurance company reimbursement policies. Analyzes insurance eligibility and coverage, and organizational standards to determine criteria concerning length of stay.

  • Reviews documentation of treatment team for medical necessity and collaborates/communicates with team when case fails to meet necessity standards.

  • Documents communication with BHOs and insurance companies in clinical record regarding Utilization Review contact/outcome.

  • Tracks patient review dates according to criteria established by BHO and insurance companies.

  • Communicates directly with BHO and insurance representatives with clinical justification for medical necessity and requests for continued stay.

  • Understands and adheres to established Organizational policies and procedures.

  • Observes confidentiality and safeguards all patient related information.

  • Attends staff meetings and Rounds as scheduled

  • Adheres to Organizational standards and consistently interprets and accurately performs all assigned responsibilities.

  • Demonstrates effective time management skills through daily documentation and infrequent overtime for routine assignments

  • Collects copays, deductibles and other self-payments from guardians of youth as necessary.

  • Demonstrates sound judgment, critical thinking and decision making.

  • Performs other duties as assigned.

  • Must be willing and able to perform physical restraints with clients using required CPI techniques.

Education/Qualifications:

  • BA degree or two years of experience in an administrative role

  • At least one year of experience in Admissions and/or Utilization Review preferred.

  • Acceptance of philosophy and goals of this Organization.

  • Ability to exercise initiative and independent judgment.

For Consideration:

  • Please apply by sending your resume, cover letter, and salary requirements with Utilization Reviewer noted in the subject line to JHillHR@jcmh.org.

  • Jefferson Hills is an Equal Opportunity/Affirmative Action Employer, M/F/V/D

  • Applicant must be 21 years or older.

NOTE: This position works in a licensed, residential child care facility. Drug screen and rigorous background check required for employment.

Jefferson Hills offers a comprehensive, affordable benefits program including health, dental and vision coverage, 403(b) with company match and long and short term disability plans. We seek to provide professional learning and development through ongoing training and a tuition reimbursement program. Jefferson Hills is an equal opportunity employer.

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