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UR and Case Manager (Nurse or Social Worker)

Company: Acadia Healthcare
Location: Murfreesboro
Posted on: July 13, 2019

Job Description:

Description The central goal of this position is to provide active operational support and clinical expertise in the areas of case management and utilization review. The Manager of Utilization Review will: - Provide direct oversight to Case Management / Utilization Review staff, refining team structures, responsibilities, and relationships to perform review and management of medical necessity of admissions to the hospital, duration of stays, professional services furnished, and delivery of required communications with Medicare beneficiaries. - Develop implementation of enhanced clinical tools, CM/UR policies and procedures to achieve standardization in process and data collection, identify areas where efficiencies can be achieved with a focus on eliminating manual processes, minimize paper files as appropriate, and evaluate current data reporting. - Actively support and participate in the Quality Improvement Programs in terms of achieving the goals and enhancing the future expansion. Will be an integral part of the team for ongoing monitoring and expansion. - Participate in quality audits, chart audits, and reviews of medical records as needed for extended length of stay, quality of care concerns, and medical necessity review. - Provide leadership to assure compliance with regulatory agencies and third party payers by ensuring that records and reports are completed for compliance with TrustPoint Hospital's quality standards and external regulatory agency requirements. - Actively participates in the denial and appeal process to initiate peer-peer reviews, write appeal letters, and file denial reconsideration reviews. Works to analyze hospital denial activity and adjust internal work processes to avoid future denials. - Coordinates and leads activities for regulatory agencies and third party payer audits for quality of care, medical necessity, coding and billing practices, and other compliance concerns. - Coordinates with the Providers in achieving continued process improvement of overall medical documentation to increase efficiency, accuracy, automation and best practice standards. Qualifications: - RN or SW with 5+ years' experience with Utilization Review and/or Case Management - 3-5 years' experience in management role - Utilization Management or Case Management Certification a plus - Strong background or knowledge of coding, clinical documentation improvement, reimbursement methodologies, and denial management - Strong and persuasive written and verbal communication skills - Knowledge of inpatient psychiatric criteria preferred, medical and/or physical medicine/rehabilitation criteria a plus - Familiarity with EHR, Microsoft Office Suite Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information.

Keywords: Acadia Healthcare, Murfreesboro , UR and Case Manager (Nurse or Social Worker), Healthcare , Murfreesboro, Tennessee

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