UTILIZATION MANAGER
Company: LESC
Location: Hillside
Posted on: October 20, 2024
Job Description:
Description:MAJOR DUTIES:
- In concert with the agency's mission and goal of sustaining
high quality care/service delivery to persons served, the
Utilization Manager works to assist CASAC Counselors and
supervisory staff as needed with assuring compliance with external
and internal utilization review/quality and appropriateness
requirements
- The Utilization Manager is responsible for the day to day
functions of collaborative communication with external case
managers at referring provider facilities and/or managed care
organizations (MCO) for data collection, interpretation and
certification/recertification from third party payers at
pre-admission through discharge, ongoing medical necessity reviews
and interdisciplinary team support with respect to MCO
requisites
- In addition, this position is responsible for having a thorough
understanding of patient treatment plans through participative
discussions with the care plan (interdisciplinary) team,
identifying and referring requests for services to the Medical
Director when guidelines are not met and reviewing residential
services requiring MCO approval
- Obtaining the required pre-authorization/certification of
specified services from the MCO and communicating end of benefit
status and/or reimbursement changes to Finance and others as deemed
necessary
- Conducting ongoing medical necessity reviews, which may be
pre-service, concurrent and/or retrospective in nature, by
evaluating clinical data and submitting appropriate documentation
to update the patient/resident's status to the MCO as
scheduled
- Acting as a liaison between the residential program and the MCO
to better facilitate the reimbursement process
- Referring MCO denials and non-covered medical services to the
directors for appeal determination and next steps
- Conducts timely and complete quality and appropriateness
reviews on a representative sample of treatment records for
residential service sites
- Provides Supervisory support to CASAC Counselors and Peer
Workers as needed with supervisory guidance from
Management/Leadership Team
- Monitors and evaluates ongoing audit for chart
- Provides direct care services to clients as needed
- Assists with the maintenance of the agency's OASAS reviews and
CARF accreditation for the program, i.e., standards review and
conformance auditing
- Performs other duties as assignedSCHEDULE: Monday-Friday
9AM-5PMRATE: $62,500 - $65,500 / year (dependent on
experience)LOCATION: NY, NY 10002We offer excellent benefits
including:
- Generous time off that includes 4 weeks of vacation
- Medical, Dental, and Vision Insurance
- Discounted Commuter benefits
- Life insurance & Long term disability
- Eligible for Federal Student Loan Repayment Program
- Training and other additional voluntary benefitsTo join our
diverse team, please include salary requirements with your
resume/application submission. Please visit us at www.lesc.org EEO
Minorities/Women/Disabled/VetRequirements:QUALIFICATIONS -
EDUCATION AND PROFESSIONAL EXPERIENCE:
- Minimum of 2 years of case management and/or utilization review
experience
- Strong problem-solving and advanced analytical skills necessary
to read, understand, interpret and analyze statistical data
- Excellent oral, written, organizational and interpersonal
communication skills
- Ability to communicate effectively with senior leadership as
well as other clinical/non clinical directors, managers, staff,
consultants and MCOs
- Demonstrated ability to effectively collaborate with peers and
senior leadership on project assignments and group
presentations
- OASAS CASAC Certification (with Bachelor's Degree)
- Other QHP credential such as LMSW, LMHC, LMSW-LP, or MHC-LP
(with Master's Degree)
- Master's Degree in Social Work or related field;
- In depth knowledge on HIPAA, OASAS, and 42 CFR regulations
- Working knowledge of quality assurance and utilization review
systems
- Computer literacy including proficiency in Microsoft Office
Suite and HER
- Experience working directly with people from diverse racial,
ethnic, and socioeconomic backgrounds
- Competency in written, interpersonal, verbal, and computational
skills to present and document records in accordance with program
standards
- Ability to work independentlyCompensation details: 62500-65500
Yearly SalaryPIdc774fe7c772-26289-34494836
Keywords: LESC, New Haven , UTILIZATION MANAGER, Executive , Hillside, Connecticut
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